Chapter 99

Otorhinolaryngology: 

Anesthetic Considerations 

Alison S. Carr and David Elliott 

99 

CHAPTER 

INTRODUCTION 

Pediatric anesthesia for ear, nose, and throat (ENT) surgery poses 

many great challenges to the anesthetist. Anesthesia for simple and 

routine ENT procedures is required in almost every hospital, and 

many of the procedures are carried out on an outpatient basis. 

Complex ENT surgery such as neonatal airway surgery is confined 

to specialist units and requires a great deal of expertise. Anesthesia 

for ENT surgery is interesting and varied: the anesthetist provides 

the tranquil operating conditions required for middle ear surgery, 

exacting anesthesia for airway obstruction, and the rapid anesthetic 

turnover required for outpatient ENT surgery. The anesthetist 

shares the airway with the surgeon in many ENT procedures, 

and many different techniques may be needed for airway management. 

Success requires vigilance and a close understanding and 

cooperation between surgeon and anesthetist. 

Acute airway obstruction will occur in any setting and 

anesthetists who work in hospitals receiving pediatric admissions 

will be called upon to manage acute airway obstruction in children. 

Airway management is often challenging, and a full range of 

airway skills needs to be mastered. 

The aims of this chapter are to discuss general and specific 

considerations for the anesthetic management of routine and 

complex ENT procedures in children. Information obtained from 

recent studies will be included where appropriate to allow an 

appreciation of the background importance of selecting appropriate 

anesthetic techniques. 

GENERAL ANESTHETIC 

CONSIDERATIONS 

Preoperative Assessment and Premedication 

Children presenting for ENT surgery often have “runny noses.” It 

is very important to assess their fitness for receiving anesthesia in 

the context of how well the child is in comparison to his or her 

usual state and how much influence surgery will have on improving 

the child’s overall clinical condition. It may well be that the child 

always has a “runny nose.” In general, a child with such symptoms 

may be anesthetized if he or she is systemically well, apyrexial, has 

clear nasal secretions, and no symptoms or signs of chest disease. 

Many children scheduled for ENT surgery have varying degrees of 

upper and or lower airway obstruction. A fastidious approach to 

the preoperative assessment of such patients should be adopted, 

and a detailed history and examination are essential before 

administering anesthesia (Table 99–1). Difficult airway management 

may be anticipated in children with certain syndromes who 

present for ENT surgery. These include children with Goldenhar 

syndrome, hemifacial macrosomia, Treacher Collins syndrome, 

Pierre Robin syndrome, and the mucopolysaccharidoses. 

A large proportion of surgical procedures are performed on an 

outpatient basis, and the use of premedication has decreased as a 

consequence. ENT anesthesia or surgery has no special requirements 

for premedication, 1,2 and standard protocols such as those 

described in previous chapters are suitable. Ametop (amethocaine 

gel 4%, tetracaine) or EMLA is widely used to provide local 

anesthesia for cannulation. The preparation is applied to the dorsi 

of both hands approximately 1 hour before anesthesia and covered 

with an occlusive dressing. 

Anesthetic Agents 

The anesthetic agent used will depend on the anesthetic technique 

chosen for the child and preferred by the anesthetist. A preference 

for intravenous or inhalational induction will depend on a number 

of factors; these may include local practice in the country where 

employed and cost. There are many different ways to anesthetize 

a child for ENT surgery, all with their own merits. Propofol has 

largely replaced thiopentone/halothane for brief ENT procedures 

in children. 3 On induction spontaneous movements and pain on 

injection were seen more frequently with propofol, although 

laryngospasm and hiccup were only seen in the thiopental group. 

Extubation occurred earlier in the propofol group, and they were 

able to be discharged from recovery in a shorter time, required 

less analgesia in the first 6 hours postoperatively, and experienced 

less postoperative nausea and vomiting (PONV) than children 

anesthetized with thiopental/halothane. Total intravenous anesthesia 

with propofol has been shown in a large meta-analysis to 

be less emetogenic than modern volatile agents. 4 A propofol 

infusion may produce a lower incidence of PONV after all 

ENT procedures due to a postulated intrinsic antiemetic effect. 5 

Anesthesia using a propofol infusion in middle ear surgery 

specifically allows the avoidance of nitrous oxide and its side 

effects. 6 Since 1992 there have been a number of case reports of 

long-term infusion of propofol causing a clinical syndrome of 

severe lactic acidosis, bradyarrhythmias, rhabdomyolysis, and 

cardiac failure with a lethal outcome. 7 In recent years there have 

been two case reports of short-term infusions for anesthesia

1700 PART 5 ■ Anesthetic, Surgical, and Interventional Procedures: Considerations 

TABLE 99-1. Common Associated Conditions in Children Presenting for ENT Surgery and Their Anesthetic Implications 

Associated Condition ENT Surgery Usually Required Anesthetic Considerations and Implications 

Vasomotor or allergic rhinitis 

Recurrent tonsillitis 

Recurrent ear infections 

Oculoauriculovertebral 

spectrum 

Treacher Collins syndrome 

Mucopolysaccharidoses 

(e.g., Hurler syndrome 

[Type I]) 

Cystic Fibrosis 

ENT = ear, nose, and throat. 

Diathermy to inferior 

turbinates; reduction of 

inferior turbinates 

Tonsillectomy 

Myringotomy and insertion of 

grommets; myringoplasty; 

adenoidectomy 

Myringotomy and grommet 

insertion; middle ear surgery 

External and middle ear 

surgery 

T 

Tonsillectomy and adenoidectomy; 

myringotomy and 

grommet insertion; mastoidectomy; 

airway surgery 

Nasal polypectomy; antral 

lavage 

May have difficulty breathing through the nose 

Children may have large tonsils impeding the insertion of a 

laryngeal mask airway (LMA) blindly (a laryngoscope may 

be helpful) 

Children with adenoidal hypertrophy may have difficulty 

breathing through the nose 

● Goldenhar syndrome, hemifacial microsomia, abnormal 

morphogenesis of the first and second branchial arches 

● Cardiac anomalies present in 35% 

● Micrognathia 

● Unilateral mandibular hypoplasia 

● Cleft palate or high arched palate 

● Malfunction of soft palate 

● Anomalies in function/structure of tongue 

● May have sleep apnea 

● Great spectrum of disease severity, difficult airway and 

difficult intubation, small mouth 

● Cleft palate or high arched palate 

● Incompetent soft palate 

● Malocclusion of the teeth 

● Narrow airway due to pharyngeal hypoplasia 

● Sleep apnea 

● Difficult airway and difficult intubation 

● Macroglossia 

● Large head 

● Nose often blocked due to adenoidal hypertrophy 

● Short, thick neck 

● Mucopolysaccharide deposition in trachea and bronchi 

produces narrowing 

● Coronary artery disease and valvular heart disease occur 

even in young children 

● Cardiomyopathy 

● Restrictive lung disease: 

thoracolumbar kyphosis 

recurrent chest infections 

● Obstructive sleep apnea (may require tracheostomy) 

● Hydrocephalus 

A genetic condition affecting exocrine glands characterized 

by abnormal composition of exocrine secretions 

● Respiratory failure 

● Recurrent chest infections with eventual bronchiectasis 

● Respiratory tract colonized by bacterial pathogens 

(Staphylococcus aureus, Haemophilus influenzae, and 

Pseudomonas aeruginosa) 

● Copious viscous secretions in the respiratory tract cause 

increased airway resistance, gas trapping, and increased 

functional . residual capacity 

● V/ Q . mismatch results in hypoxia (PaCO 2 

usually normal) 

● Reduced lung compliance 

● Pancreatic insufficiency 

● Malnourished 

● Occasionally diabetic 

● May have biliary fibrosis and cirrhosis

CHAPTER 99 ■ Otorhinolaryngology: Anesthetic Considerations 1701 

causing severe metabolic acidosis. 8,9 Despite this, propofol has 

become widely established in pediatric ENT surgery for the 

induction and maintenance of anesthesia, alone and in conjunction 

with short-acting opioids. Additional clinical studies regarding 

this rare yet potentially lethal syndrome are required to further 

understand its pathophysiology and provide guidance for the 

anesthetist using total intravenous anesthesia (TIVA). 

Sevoflurane has succeeded halothane as the inhalational agent 

for gaseous induction in children in many institutions. In anesthesia 

for ENT surgery, sevoflurane maintains heart rate and blood 

pressure better than equianesthetic concentrations of halothane 

and the incidence of cardiac arrhythmias is significantly lower 

with sevoflurane. 10 Sevoflurane is used for the induction of anesthesia; 

its cost, however, may preclude its use for the maintenance 

of anesthesia. Isoflurane is a useful alternative for the maintenance 

of anesthesia in ENT surgery because of its rapid wakening 

properties, safety in the presence of exogenous catecholamines, 12 

and minimal emesis. 

Anesthesia and the Shared Airway 

Anesthesia for nose and throat surgery requires sharing the airway 

with the surgeon; this poses several potential problems for the 

anesthetist. The chosen technique must ensure that adequate 

ventilation of the lungs occurs and that the airway remains 

patent and protected throughout surgery. The technique adopted 

depends on whether surgery is performed above or below the 

vocal cords. When nasal or pharyngeal surgery is performed the 

anesthetist must ensure that the anesthetic technique protects 

the airway below. Laryngeal, tracheal, or bronchial surgery is 

even more challenging. The anesthetist must maintain adequate 

ventilation and depth of anesthesia while allowing the surgeon to 

operate in an unobstructed field. 

Airway Protection 

In surgery on the nose and pharynx the anesthetist must ensure 

that the lower airway is secure and protected from contamination 

by secretions or blood. The airway must also be protected from 

the possibility or regurgitation and aspiration of gastric contents, 

for example, during anesthesia for exploration of a posttonsillectomy 

bleed or in any case where it is clinically indicated. 

Tracheal Intubation 

Intubation of the trachea remains the gold standard for protecting 

the airway. Preformed oral endotracheal tubes, for example, the 

oral RAE tube, are particularly useful for ENT procedures because 

the caudally directed tube and peripherally placed connector allow 

access to the airway by the surgeon. Intubation may be performed 

under deep inhalational anesthesia or after an I.V. intubating dose 

of a neuromuscular blocking agent. Topical local anesthesia to the 

larynx before intubation after inhalational induction reduces the 

depth of anesthesia required. 

Lidocaine 4% is usually used for local anesthesia of the larynx 

and trachea. Caution should be observed not to exceed the 

maximum safe dose of 4 mg/kg in children. In small infants cardiac 

arrest and heart block have been reported after topical local 

anesthesia, and the total dose in this age group should be reduced. 

In the absence of upper airway obstruction suxamethonium 1 

to 2 mg/kg may be used to facilitate endotracheal intubation. 

There have been case reports of hyperkalemic cardiac arrest in 

children with undiagnosed myopathies. 13,14 The likelihood of an 

undiagnosed myopathy is very rare and its risk should be carefully 

balanced against the risk associated with difficulty in maintaining 

an airway or intubating the trachea in the absence of suxamethonium. 

A nondepolarizing agent may be used to facilitate 

endotracheal intubation in the absence of upper airway obstruction. 

The child can be extubated when deeply anesthetized or 

when he or she is awake. 

DEEP EXTUBATION: The potential advantages of deep extubation 

are manifold. There is minimal irritation to the trachea and 

pharynx, allowing the child to emerge peacefully. This reduces 

coughing, laryngospasm, and postoperative bleeding. The disadvantages 

of deep extubation are leaving the airway potentially 

unprotected and thereby depending on nursing diligence, 

position, and airway suctioning to prevent aspiration. 

AWAKE EXTUBATION: The main advantage of awake extubation is 

early protection. However, the airway protection conferred by an 

awake extubation compared to a deep extubation may not be as 

good as previously considered. 15,17 The potential disadvantages of 

awake extubation are irritation of the trachea and pharynx with 

resultant coughing, retching, vomiting, increased postoperative 

bleeding, and laryngospasm on emergence. 

There are strong proponents for each method of tracheal 

extubation. A study of complications during emergence compared 

awake and deep extubation in otherwise healthy children undergoing 

elective surgery. 17 In the deep extubation group, oxygen 

saturations were higher for the first 5 minutes, and there was no 

difference in the incidence of postoperative airway-related complications 

between the two groups. The study concluded that the 

anesthetists’ preference or surgical requirements should dictate 

the choice of extubation requirements. 

Laryngeal Mask Airway 

The LMA was introduced into anesthetic practice in the United 

Kingdom in 1985. Since that time clinicians around the world have 

chosen to use the LMA over 200 million times. Indications for the 

LMA have increased exponentially and it has established itself as 

one of the most respected supraglottic airway devices in the world 

(Table 99–2). The laryngeal mask airway is inserted into the 

pharynx, forming a low-pressure seal around the laryngeal inlet. 

It can be quickly and easily inserted without muscle relaxants or 

deep anesthesia and allows the administration of inhalational 

agents through a nonstimulating airway. 18 It secures the airway, 

protecting against soiling of the larynx with blood, maintains a 

patent airway throughout the surgical procedure, and allows 

adequate surgical access. 16,19 The LMA does not protect against 

aspiration of gastric contents and should not be used in the 

presence of a full stomach or gastric reflux. Most techniques using 

the LMA involve spontaneous respiration. The LMA has also been 

used to safely and efficiently provide intermittent positive-pressure 

ventilation (IPPV) for short procedures. 20 IPPV via the LMA is 

not commonly performed due to the potential risk of gastric 

insufflation. When IPPV is used it should be controlled so that 

the peak airway pressure does not exceed the cuff leak pressure of 

the LMA, usually equal to 15 cm H 2 

O. 

The armored LMA 21 has been shown to be useful in many types 

of ENT procedures in children. 22,23 The successful use of this


reinforced LMA has been described in the use of more than 800 

tonsillectomies and has established itself as an alternative to 

endotracheal intubation. Using a small LMA and a small gag 22 

minimizes obstruction of the airway on insertion of the Boyle- 

Davis (BD) gag. Occasionally intubation may be necessary if 

obstruction persists after inserting the BD gag. The flexible stem 

of the reinforced LMA can be folded over the lower lip and can be 

secured over the lower jaw in a similar fashion to an oral RAE tube 

or left free to allow some flexibility in inserting a BD gag. The 

LMA has been shown to provide adequate surgical access with less 

aspiration of surgical blood than with tracheal intubation. 15,17,22 

There are several studies demonstrating the effectiveness of the 

LMA in protecting the lower airway from soiling. In one study the 

LMA effectively prevented tracheal aspiration of methylene blue 

injected into the mouth through the pharynx. 24 When tracheal 

intubation and the reinforced LMA were compared for adenotonsillectomy, 

aspiration of blood into the lower airway occurred 

with a tracheal tube (21 out of 39) but did not occur with an LMA 

(0 out of 24 children). 12 In the tracheal intubation group aspiration 

of blood reached the larynx in 13/39 cases, the trachea in 5 cases, 

and the carina in 3 cases. 

Recovery from anesthesia in children with the LMA in place 

was superior to that in deep or awake tracheal extubation. In two 

of the studies already mentioned, there was a lower incidence of 

airway obstruction, coughing on insertion or removal, and less 

oxygen desaturation. 15,22 LMA use has also been shown to be less 

frequently associated with postoperative laryngospasm and 

coughing in recovery. 16,19 Since the advent of the disposable 

reinforced LMA, many anesthetists in the United Kingdom have 

adopted this for pediatric adenotonsillectomy, for operations on 

the upper airway, and for most ENT surgical procedures. 

Monitoring 

Standard monitoring is required for all ENT procedures; this 

should include ECG, pulse oximetry, noninvasive blood pressure 

measurement, capnography, and gas analysis. Where indicated the 

use of a nerve stimulator, temperature measurement, and ventilator 

disconnection alarm should be employed. Minimum standards 

in the recovery room should include noninvasive blood pressure, 

ECG, and pulse oximetry. 

Postoperative Analgesia 

Requirements for postoperative analgesia vary depending on 

the individual child and the type of surgical procedure. The use 

of opioid analgesia and nonsteroidal anti-inflammatory drugs 

(NSAIDs) is discussed in detail. 

Nonsteroidal Anti-Inflammatory Drugs 

Paracetamol or acetaminophen remains the mainstay of analgesia 

in pediatric anesthesia. It should be prescribed orally as a premedication 

if appropriate or administered rectally at induction and 

should be continued orally into the postoperative period. Its regular 

use may reduce perioperative opioid requirements and, thus, 

reduce the incidence of side effects attributed to perioperative 

opioid use, in particular PONV. Paracetamol is often undervalued; 

even for moderate pain it is generally an effective analgesic 

in the younger child. 25 The recommended loading dose for 

paracetamol is 40 mg/kg PR followed by 15-20 mg/kg orally or PR 

every 6 hours to a maximum dose of 90 mg/kg in 24 hours. 

Intravenous preparations of paracetamol have been available for 

some time now, initially in the form of proparacetamol 28 and more 

recently in the form of a paracetamol solution. Proparacetamol 

is hydrolyzed by plasma esterases, and 50% of the infused drug 

is converted into paracetamol. Proparacetamol 30 mg/kg is administered 

every 6 hours in the form of a short intravenous infusion 

and is the equivalent of 15 mg/kg of oral paracetamol. 

Proparacetamol has been succeeded by an I.V. paracetamol 

solution containing mannitol and disodium phosphate to aid 

solubility at room temperature. Proparacetamol seemed to be more 

allergenic than intravenous paracetamol, as N,N-diethylglycine 

causes sensitization in human skin. 27 Proparacetamol is also 

considerably more expensive than intravenous paracetamol, partly 

because it needs to be reconstituted with sodium citrate. 

NSAIDs have become widely used for perioperative analgesia 

in pediatric ENT anesthesia. They have been shown to be equipotent 

to opioids in a number of studies. 28–30 The use of an NSAID 

in comparison to an opioid offers the advantages of less respiratory 

depression and a child who is awake and comfortable at an 

earlier time postoperatively. 30 NSAIDs all inhibit prostaglandin 

synthetase, resulting in a reduction of platelet function. This 

effect is irreversible for aspirin but reversible for other NSAIDS 

TABLE 99-2. A Comparison of the Laryngeal Mask Airway With the Endotracheal Tube for Pediatric ENT Anesthesia 

Characteristic Laryngeal Mask Airway Endotracheal Tube 

Ease of insertion 

Airway protection: From blood and 

debris from the airway above 

From aspiration of gastric protection 

Emergence characteristics 

Inserted blindly into the pharynx without 

I.V. muscle relaxant or deep anesthesia 

Secures and protects airway better than 

ETT (Nair I, 1995) (Boisson-Bertrand, 

1995) (Williams PJ, 1993) 

No protection 

Smooth: Lower incidence of 

laryngospasm, coughing on removal, 

and oxygen desaturation in 

comparison to deep or awake tracheal 

extubation (Nair I, 1995) (Boisson- 

Bertrand, 1995) (Williams PJ, 1993) 

(Webster AC, 1993) 

Requires I.V. muscle relaxant or deep 

anesthesia; performed at laryngoscopy 

under direct vision 

Secures and protects airway less successfully 

than previously thought (Williams 

PJ, 1993) 

Protects 

Higher incidence of laryngospasm, 

coughing on removal, and oxygen 

desaturation than the LMA (Nair I, 

1995) (Boisson-Bertrand, 1995) 

(Williams PJ, 1993) (Webster AC, 1993)


such as indomethacin, ketorolac, and diclofenac. Concerns 

regarding their use and the increased risk of perioperative 

bleeding have been expressed, particularly with regard to adenotonsillectomy 

when there is an incidence of primary hemorrhage. 32 

Ketorolac in particular has been associated with an increased 

incidence of perioperative blood loss 33,34 and of early posttonsillectomy 

hemorrhage. 29 Increased blood losses were also observed 

with administration of indomethacin but not after administration 

of diclofenac. 35 Diclofenac given I.M. at induction had little, if any, 

effect on blood loss in the OR at tonsillectomy in children or on 

the proportion of children bleeding postoperatively or returning 

to the operating theater for hemostasis. 36 NSAIDs can be very 

beneficial in the management of postoperative pain in children, 

and this should be borne in mind when assessing risk. In some 

studies increased bleeding certainly has been shown with NSAIDs, 

and as such they should be avoided for tonsillectomy in children 

in whom increased blood loss or reduced platelet function 

poses particular risks. 37 Care is required with nonparacetamol 

NSAIDs in infants because of the immaturity of renal function, 

and dosing intervals in the neonate should be longer due to 

reduced clearance. 37 NSAIDs should be avoided in children with 

proven asthma, especially if associated with nasal polyps, severe 

eczema, or atopy. 37 

The recommended daily dose of diclofenac is 3 mg/kg in 

three divided doses either orally or rectally. Initial doses can be 

administered rectally or intravenously after induction of anesthesia 

and subsequent doses prescribed orally or rectally on the 

unit afterward. Whenever possible child-friendly oral syrups 

should be used in the awake child. 

Opioid Analgesia 

Opioids are required for major surgery (middle ear surgery) and 

occasionally for intermediate procedures (adenotonsillectomy). 

Judicious doses of opioids given at induction will provide good 

pain relief into the postoperative period. The drawback with the 

administration of standard doses of morphine (100 µg/kg) is that 

some children who require only a small dose of opioid to control 

their pain will be induced to vomit. 25 Instead, morphine 50 µg/kg 

or fentanyl 1 µg/kg should be administered every 10 units until 

the child is comfortable. On the unit Oramorph (morphine syrup 

formulation) 0.5 mg/kg can be given every four hours or 

morphine 50 µg/kg I.V. should be administered as required. 

Postoperative Nausea and Vomiting 

PONV is approximately twice as frequent in the pediatric 

population compared with adults, with an incidence of between 13 

and 42% in all pediatric patients. 38,39 Severe PONV can result in a 

variety of complications, including wound dehiscence, dehydration, 

electrolyte imbalance, and pulmonary aspiration. 40 It is the 

leading cause of unanticipated hospital admission and parental 

dissatisfaction following outpatient ambulatory surgery with 

resultant increase in health care costs. 41,42 Unfortunately, PONV 

remains a frequent complication of surgery and anesthesia in 

children, particularly in the older child and in the child who 

receives long-acting opioid analgesia. 47 Given that a large 

proportion of ENT procedures are carried out on an outpatient 

basis, minimizing PONV is crucial to success. 

ENT surgery has long been believed to be a risk for PONV; 

however, only two procedures have actually been shown to be 

independent risk factors for PONV in children. Without antiemetic 

prophylaxis, a high proportion of children undergoing adenotonsillectomy 

will experience at least one episode of postoperative 

vomiting (89% without prophylaxis in one series). 43–45 However, 

many of these studies suffer from the drawback of the compounding 

effect of perioperative opioid administration that may 

be acting as a surrogate risk factor, as in the absence of opioids in 

one study only 11% of children vomited. 46 Scrupulous surgical 

technique to decrease swallowed blood, avoidance of long-acting 

opioid analgesia, and appropriate prophylactic antiemetics are key 

to avoiding PONV. Otoplasty in children is recognized for its 

emetic potential with an incidence of vomiting in the absence of 

antiemetic prophylaxis of up to 60%. 48 However, surgical dressings 

(in particular packing of the external ear canal) may influence the 

incidence of PONV in these patients. 49 

A Cochrane analysis in 2003 demonstrated that children 

undergoing tonsillectomy who were given a single dose of 

dexamethasone IV were half as likely to vomit in the first 24 hours 

after surgery. 50 A further study of 200 children showed that ondansetron 

in combination with dexamethasone significantly 

reduced PONV more than ondansetron alone. 51 A recent Association 

of Anaesthetists of Great Britain and Ireland (AAGBI) 

guideline for the management of PONV in children has recommended 

that children scheduled for adenotonsillectomy should 

receive combination therapy. 

SPECIFIC ANESTHETIC 

CONSIDERATIONS 

Anesthesia for Ear Surgery 

General Considerations 

Children undergoing ear surgery often require multiple procedures 

and may also suffer from a degree of hearing impairment. The 

anesthetist must gain the trust of such children. Often, having some 

control of their induction along with appropriate explanation can 

help the child to relax preoperatively. If parents have been present 

during a previous induction of anesthesia they may be able to 

provide valuable information about the child’s behavior. The calm 

quiet child seen on the unit preoperatively may not have been the 

child who was managed with difficulty in the anesthesia room. 

These considerations may influence the decision about the use 

of premedication. 

Anesthesia for Myringotomy 

and Insertion of Grommets 

Grommet insertion is usually performed as an outpatient procedure. 

Some children may require multiple operations and may 

be reluctant to be given another anesthetic. Many suffer from 

recurrent upper respiratory tract infections. Some congenital 

syndromes and deformities of the upper airway predispose to the 

development of ear problems. Generally, anesthesia is a very short 

procedure. Induction can be inhalational or intravenous with 

inhalational maintenance via a face mask or an LMA. A major 

advantage of the LMA is that the surgeon no longer has to compete 

with the anesthetist’s hand in relation to the restricted surgical 

field compared to the usual method of face mask anesthesia. 18 

However, the use of an LMA is more costly and some would argue 

that for a short procedure, the competence in airway management 

and the ability to hold the head still could quickly be learned using 

a mask and airway.


As myringotomy is such a short procedure, oral paracetamol 

or NSAIDs should be given 30 minutes preoperatively to ensure 

adequate analgesia at the end of the case. Opioids are effective but 

are generally not required. 

Anesthesia for Middle Ear Surgery 

Children scheduled for middle ear surgery may undergo mastoidectomy, 

tympanoplasty, or myringoplasty. Anesthesia should 

provide optimal surgical conditions; a bloodless field permit 

the surgeon to operate through a microscope. Providing these 

conditions can be challenging. A smooth induction and careful 

attention to detail throughout anesthesia are required. PONV is 

very common and the drugs used should be selected to minimize 

postoperative emesis. Propofol has been shown to reduce PONV, 52 

but it is not an effective means to reduce postoperative emesis after 

middle ear surgery in children. 53 The high incidence of PONV 

after middle ear surgery justifies the use of combined prophylactic 

antiemetic medication at induction of anesthesia. Ondansetron 

and granistron have both proved to be effective at reducing PONV 

after middle ear surgery. 54,55 When the surgeon performs surgery 

through a postauricular incision, the facial nerve, having emerged 

from the stylomastoid foramen, lies superficially in close proximity 

and is prone to damage. A nerve stimulator is often used by 

the surgeon to locate the facial nerve during the procedure. If a 

muscle relaxant is used during induction of anesthesia, its effects 

should not persist when the nerve stimulator is used. 

Premedication may allay anxiety (especially if the child has 

undergone multiple procedures) and allows the child to arrive in 

the OR in a relaxed and tranquil state. Induction of anesthesia may 

be intravenous, by propofol 3 to 4 mg/kg, or by inhalation, 

depending on preference. Once I.V. access has been secured, an 

antiemetic, for example, dexamethasone/ondansetron 0.15 mg/kg, 

or dimenhydrinate 0.5 mg/kg, should be administered. An opioid 

analgesic such as fentanyl 1 to 2 µg/kg I.V. should also be administered. 

Tracheal intubation may be facilitated by a short- acting 

neuromuscular blocking agent or by deep inhalation. The vocal 

cords may be sprayed with lidocaine 4 mg/kg. A preformed 

caudad-facing tracheal tube, such as the RAE tube, may be 

preferred. 

Optimal surgical conditions will be encouraged by a smooth 

induction, without crying, coughing, or straining. The anesthetized 

child should have a slower pulse than usual and a slightly 

lower blood pressure. Labetolol may be given in boluses of 0.2 

mg/kg every 5 minutes to optimize cardiovascular parameters if 

necessary. The child should be placed on the operating table with 

a head-up tilt of 20 degrees with the head positioned carefully to 

avoid venous obstruction. The surgeon may infiltrate the incision 

site with lidocaine with epinephrine to further reduce bleeding. 

Greater auricular nerve block has been shown to be a useful 

analgesic adjunct; it can provide similar analgesia to opioids 

resulting in reduced PONV. 56 Anesthesia can be maintained with 

a volatile agent or a propofol infusion. Boluses of fentanyl should 

be administered as required. Nitrous oxide increases middle ear 

pressure 57 and if used, should be discontinued and replaced with 

air 15 minutes before tympanic grafting occurs. 

An alternative technique for middle ear surgery uses total 

intravenous anesthesia with remifentanil and propofol. Remifentanil 

is infused at 0.25 to 0.5 µg/kg/min and propofol at 6 to 

9 mg/kg/hr after an induction dose of 3 to 5 mg/kg. Remifentanil 

is an opioid with a unique pharmacokinetic profile. Its metabolism 

by nonspecific plasma esterases results in a rapid uniform 

clearance leading to a predictable onset and duration of action 

that is independent of bolus dose or duration of infusion. The 

remifentanil-propofol technique provides superior operating 

conditions during middle ear surgery by facilitating control of 

heart rate and blood pressure. 58 The remifentanil infusion can be 

adjusted to provide rapid control of heart rate and blood pressure. 

In addition, bolus doses of up to 1 µg/kg may be injected as 

required. With this technique, it is rarely necessary to use additional 

drugs to control blood pressure during middle ear surgery. 

Anesthesia for Cochlear Implant Surgery 

Cochlear implantation is a widely used means of treating deafness 

and severe hearing disorders in both adults and children. The 

implant causes direct stimulation of the auditory nerve, enabling 

hearing. Children attending for cochlear implant surgery may 

have associated syndromes that present a considerable challenge 

to the anesthetist. The surgery itself consists of inserting a cochlear 

implant electrode array into the cochlea and embedding the signal 

receiver in the mastoid bone just behind the ear. The surgery is 

time-consuming and complicated. As with middle ear surgery the 

anesthetist must provide optimal conditions that facilitate the use 

of nerve stimulators and provide a bloodless field to enable the 

surgeon to operate through a microscope. 

Parental presence is highly desirable during induction of 

anesthesia, since a lack of communication is a big hurdle in 

establishing rapport. Anesthesia for cochlear implantation surgery 

should follow the same smooth induction and maintenance as for 

middle ear surgery; TIVA with remifentanil is ideal for producing 

such conditions. Once fitted, the appropriate level of stimulation 

is guided by electrically evoked responses. General anesthesia has 

been shown to affect these responses, producing erroneous 

readings, with the volatile agents having the greatest effect on 

intraoperative measurements. 59 Traditionally, volatile anesthetic 

agents are kept to a bare minimum during this part of the 

operation to reduce any effect on measured potentials. One study 

suggested that the use of electroencephalogram monitoring during 

cochlear implantation might be of value in titrating inhalational 

anesthesia to reduce its effect on measured response values. 60 By 

contrast, total intravenous anesthesia with propofol has been 

shown to have significantly less effect on measured responses. 61 

Anesthesia for Operations 

on the Nose and Pharynx 


Children undergoing nasal surgery very often have a degree of 

nasal airway obstruction. This is particularly important in infants 

who are obligate nasal breathers. A vasoconstrictor is often used 

for the nasal mucosa to minimize bleeding. Cocaine or a local 

anesthetic with adrenaline or phenylephrine may be used. Cocaine 

may be associated with an increased incidence of cardiac 

arrhythmias. This was seen most commonly when it was used in 

conjunction with halothane. Cocaine has been used to provide 

topical nasal anesthesia and vasoconstriction for more than a 

century due to its availability, low cost, and inherent vasoconstrictor 

properties. 62 Despite this, there are many potential


problems with the therapeutic use of cocaine. The vasoconstriction 

produced may be marked and, although unlikely in children, 

myocardial infarction and sudden death from heart failure have 

been reported after use of topical cocaine in adults. 62 

The airway must be protected from blood and debris from the 

nose during surgery. Tracheal intubation or insertion of a 

reinforced LMA should be performed. A throat pack should be 

inserted into the pharynx to further reduce the risk of aspiration 

of any blood that may collect there. The throat pack is removed 

and the pharynx suctioned prior to extubation. Suction under 

direct laryngoscopy may be performed before extubation to 

remove any blood or debris. Nasal packs may be inserted at the 

end of surgery to control bleeding. These may be soaked in 

epinephrine or phenylephrine to cause local vasoconstriction. 

Marked systemic absorption of these drugs may occur. Nasal 

packs prevent breathing through the nose, and this must be 

considered during emergence from anesthesia. The endotracheal 

tube may be left in situ until the child is awake or an oropharyngeal 

airway may be inserted if the child is extubated when deeply 

anesthetized. If an LMA is used it may be left in situ until the child 

is awake. Children with nasal polyps frequently have cystic 

fibrosis, and the perioperative care should be directed toward the 

associated problems. 

Anesthesia for Choanal Atresia 

Choanal atresia occurs in less than 1 in 10,000 live births and may 

be bony or membranous. Bilateral choanal atresia presents shortly 

after birth. Neonates are obligatory nasal breathers and acute 

respiratory compromise with hypoxemia will quickly progress to 

death without intervention. Immediate control can be achieved 

by the insertion of an oropharyngeal airway that should initially be 

secured in place with tape and then sutured in. Loss of the 

pharyngeal airway would result in airway obstruction and the 

probable death of the baby. Thus, in many hospitals, suturing is 

standard practice. The infant should be fed via an orogastric tube. 

Unilateral atresia does not cause respiratory problems and may go 

undiagnosed for many years. Choanal atresia may be associated 

with other congenital defects, for example CHARGE syndrome 

(coloboma, heart defect, atresia of choanae, retarded mental 

development, genital hypoplasia, and ear defect with deafness). 

All the precautions usually required for anesthetizing an infant 

must be taken. With bilateral choanal atresia the child should be 

anesthetized with the oral airway left in situ. Anesthesia may be 

induced intravenously or via inhalation. An anticholinergic may 

be administered intravenously before orotracheal intubation, 

which may be under deep inhalation or using a muscle relaxant 

after confirming the ability to manually ventilate the lungs. 

Anesthesia may be maintained with an inhalational agent and 

intermittent positive-pressure ventilation. Surgery is performed 

via an endonasal or transpalatal route. The endoscopic endonasal 

approach in the management of choanal atresia is a simple, safe, 

and reliable procedure. 64 Dilators or a shielded dental drill is used 

to treat choanal atresia. Stents are inserted and left in place for 3 

to 6 months. At the end of the procedure, the pharynx must be 

suctioned and the trachea extubated when the baby is awake. 

Postoperatively, supplemental humidified oxygen should be given 

and the stents should be suctioned regularly. The infant should be 

carefully observed when feeding to avoid aspiration. 

Anesthesia for Manipulation 

of Nasal Fractures 

Manipulation of nasal fractures under anesthesia is usually a brief 

procedure. The main consequence that must be considered is 

bleeding from the nose into the airway. The airway must be 

protected from aspiration of blood, either by tracheal intubation 

and a throat pack or the use of an LMA. 

Anesthesia for Functional 

Endoscopic Sinus Surgery 

Children commonly undergo functional endoscopic sinus surgery 

(FESS) for acute or chronic sinusitis or choanal and nasal 

polyposis. Ethmoidectomies, sphenoidectomies, maxillary antrostomies, 

and nasal polypectomies are examples of the operations 

performed under FESS. 65 Associated conditions include cystic 

fibrosis, allergy, and immunodeficiency. As for any nasal procedure, 

the airway must be protected either by endotracheal tube 

and pack or LMA. Of note, however, is the use of nasal packs and 

infiltration perioperatively of cocaine or local anesthetics with 

vasoconstrictors. Marked and unpredictable systemic absorption 

of locally administered vasoconstrictors has been shown. 66 There 

may be an increased incidence of cardiac arrhythmias, especially 

if halothane is used. In some centers phenylephrine-soaked packs 

are inserted at the end of surgery. Marked absorption of phenylephrine 

may occur requiring the administration of a drug with 

alpha-blocking properties, for example, phentolamine 0.1 mg/kg 

I.V., to prevent hypertension. Labetolol 0.25 mg/kg is a suitable 

alternative, but it should not be used in asthmatic children because 

of its beta-blocking activity. 

Anesthesia for Adenotonsillectomy 

Adenoidectomy is usually performed to relieve nasopharyngeal 

obstruction, which usually manifests itself as mouth breathing, 

snoring, and eustachian tube obstruction with associated recurrent 

otitis media. The main indication for tonsillectomy is 

recurrent tonsillitis; however, chronic upper airway obstruction 

and peritonsillar abscess are rarer indications. 

Specific Anesthetic Concerns 

POSTOPERATIVE NAUSEA AND VOMITING: Persistent PONV and 

poor oral intake are the commonest cause of unscheduled hospital 

admission after outpatient pediatric adenotonsillectomy. 67 PONV 

is the greatest cause of morbidity after adenotonsillectomy. Premedication, 

intravenous induction agents, inhalational agents, 

antiemetics, and analgesics have all been evaluated as contributors 

to PONV after adenotonsillectomy. Premedication with oral 

trimeperazine (4 mg/kg) has been shown to reduce the incidence 

of PONV after adenotonsillectomy. 1 The use of oral benzodiazepines 

as a premedication is not as effective in reducing PONV. 68 

Preoperative oral ondansetron is effective in reducing PONV in 

preadolescents after tonsillectomy. 69 The oral route is as effective 

as the intravenous route for the administration of ondansetron in 

preventing PONV in children. 70 The use of a variety of prophylactic 

antiemetics given at induction has been shown to reduce the 

incidence of postoperative emesis. 71–76 Midazolam given intravenously 

after induction of anesthesia has also been shown to


reduce PONV and the incidence of unscheduled admissions 

caused by PONV. 77 5HT 3 

antagonists have been shown to be highly 

effective antiemetics in children and produce few undesirable 

effects. 78–80 Since the mid-1990s there has been increasing evidence 

supporting the use of intraoperative dexamethasone during pediatric 

tonsillectomy 81 not only as an antiemetic but also to improve 

postoperative analgesia. In 2003 a Cochrane review concluded that 

children given dexamethasone were half as likely to vomit in the 

first 24 hours following tonsillectomy than those given placebo. 50 

A meta-analysis 3 years later showed significantly improved pain 

scores 24 hours after surgery in those children given dexamethasone 

compared with placebos. 82 Ondansetron combined with 

dexamethasone increases the effectiveness of preventing PONV 

in children. 51 

Ondansetron combined with dexamethasone is the antiemetic 

of choice in our institution for outpatient pediatric tonsillectomy. 

POSTOPERATIVE HEMORRHAGE: Bleeding after tonsillectomy may 

be life threatening and children still die each year following this 

procedure. 83,84 Posttonsillectomy bleeding occurs in about 1 to 2% 

of children in the first 24 hours after surgery. Only 0.06% require 

a second general anesthetic to achieve hemostasis. 85,86 The incidence 

of posttonsillectomy hemorrhage can be linked to surgical 

technique: a higher rate of postoperative bleeding was seen in 

mechanical tonsillectomies (7.6%) compared with electrocautery 

tonsillectomies (2.8%). 87 A higher rate of reactive hemorrhage 

requiring reoperation was seen after dissection tonsillectomies 

(1.8%) compared to guillotine tonsillectomies (0%). 88 Upper airway 

infection, knife dissection, and increased intraoperative 

bleeding were found to be associated clinically and statistically 

with primary postoperative hemorrhage. 89 . 

In 2001, the U.K. Department of Health issued a recommendation 

that single use instruments should be used for adenotonsillectomy 

following advice from the Spongiform Encephalopathy 

Advisory Committee. This formed part of a larger campaign 

aimed at reducing the risk of transmission of variant Creutzfeld- 

Jacob disease. In the following 12 months there were reports of 

higher levels of complications, particularly hemorrhage, with some 

of the single use instruments. Concerns over increased complications 

led to a number of studies. One study demonstrated a 

fourfold increased risk of postoperative hemorrhage with single 

use cold steel, ties, and packs compared with reusable instruments. 

90 However, this study was limited by small numbers in the 

single use group. 

INPATIENT PROCEDURE: Adenotonsillectomy is often performed 

as an inpatient procedure in many parts of the world. In the United 

Kingdom in 2002 the Department of Health included tonsillectomy 

in a list of suitable operations for outpatient surgery in the 

report Day Surgery: An Operational Guide. Safe and successful day 

case tonsillectomy requires careful patient assessment and selection. 

Children who are candidates for outpatient adenotonsillectomy 

should be over 3 years old, in good overall health, have no 

central or obstructive sleep apnea, have a normal bleeding history, 

live within 1 hour of the hospital, and have adequate social circumstances. 

91,92 Primary hemorrhage, protracted emesis, and fever 

have the greatest incidence in the first 6 hours postoperatively. 

Children should remain in the hospital for this time period before 

discharge home. 86 Parents whose children are discharged from the 

hospital the same day should be given clear verbal and written 

advice of when to seek medical assistance postoperatively. 

Anesthetic Technique 

GENERAL CONSIDERATIONS: There are many possible ways of 

anesthetizing a child for adenotonsillectomy. Anesthesia was 

classically induced by either inhalation with halothane, nitrous 

oxide, and oxygen or by thiopental I.V. and maintained via 

inhalation with I.V. morphine up to 0.1 mg/kg. The incidence of 

emesis with this technique is 70 to 73%. 74,93 Modern inhalational 

anesthetics also do not protect against emesis; one study 

demonstrated that sevoflurane in nitrous oxide for adenotonsillectomy 

or strabismus repair produced postoperative vomiting in 

65% of children. 76 There is also no difference in postoperative 

vomiting rates with use of spontaneous respiration or positivepressure 

ventilation. 94 A propofol infusion, nitrous oxide, and 

oxygen for maintenance of anesthesia after a gaseous induction 

have been shown to reduce PONV in the first 24 hours to 21% 

compared with 55% with inhalational maintenance. 95 Analgesia 

was paracetamol 10 to 15 mg/kg rectally and fentanyl 2 to 4 µg/kg. 

Ved and colleagues showed maintenance with a propofol infusion 

produced 3.5 times less vomiting than halothane. 96 Postoperative 

vomiting in the first 8 hours affected only 27% of children given a 

propofol induction and maintenance with either halothane or 

isoflurane and analgesia provided by fentanyl and diclofenac. 97 

This is the standard anesthetic for adenotonsillectomy at this 

institution, combined with preoperative oral paracetamol; it has 

been successfully used for many thousands of adenotonsillectomies. 

Intravenous or intramuscular morphine (0.1 mg/kg) has 

long been the gold standard for perioperative analgesia for 

adenotonsillectomy. Its use is associated with a high incidence of 

postoperative vomiting 25 and it may not be necessary in all cases. 

Many children find postoperative vomiting at least as distressing 

as posttonsillectomy sore throat. It has been suggested that fulldose 

morphine (0.1 mg/kg) to provide long- lasting analgesia is 

not justified. 25 Pain after tonsillectomy is very variable and it is 

recognized that a proportion of children will require opioid analgesia 

postoperatively. 25 Other alternatives used include codeine 

phosphate, tramadol, and ketamine. 98–100 Tramadol produces 

similar analgesia and side effects to pethidine and morphine. One 

study demonstrated less nausea with tramadol than with morphine. 

101 In patients with obstructive sleep apnea tramadol 

was associated with fewer episodes of postoperative desaturation 

after adenotonsillectomy. 99 Ketamine improves analgesia when 

compared to placebo but has no benefits when compared to 

equianalgesic opioids and may increase side effects. 100,102,103 Not all 

children require opioid analgesia for posttonsillectomy pain, 

and most can be managed on a combination of NSAIDs and 

paracetamol. 25 

The influence of NSAIDs on postoperative bleeding after 

tonsillectomy has been widely debated. Many hospitals in the 

United Kingdom have been using NSAIDs routinely for postoperative 

analgesia for a number of years. The benefits of opioid 

sparing and reduced PONV are balanced against a possible 

increased risk of bleeding. The Royal College of Anaesthetists has 

recommended avoiding the use of NSAIDs in children with an 

increased risk of bleeding or reduced platelet function. 104 Another 

method for providing perioperative analgesia for tonsillectomy is 

with regional anesthesia. The oropharynx and the tonsillar fossae 

are well innervated locally by branches of the glossopharyngeal 

and trigeminal nerves, which are amenable to block by local 

anesthetics. The absence of respiratory depression associated with 

opioid-based anesthetic techniques promotes this method of 

analgesia as especially suitable for outpatient tonsillectomy.


One study using lidocaine 1% topical spray, 4 mg/kg, evenly 

distributed on the tonsillar beds, showed considerable improvement 

in pain scores in the immediate postoperative period after 

tonsillectomy when compared with codeine phosphate 1.5 mg/kg 

intramuscularly. 105 Preincisional infiltration in the anterior tonsillar 

pillar with local anesthetic, for example 1/200,000 adrenaline 

and 0.25% bupivicaine, has been shown to cause a remarkable 

reduction in the intensity of postoperative pain, well beyond the 

immediate postoperative period in some studies. 106,108 Tonsillar 

fossa local anesthetic injection reduced visual analog score (VAS), 

improved oral intake, and reduced referred ear pain. 109–111,113 

Peritonsillar infiltration, although a simple technique in skilled 

hands, has been associated with major morbidity. The possible 

complications have been described in a report of over 1000 patients 

receiving a mixture of lidocaine, methylprednisolone, and penicillin. 

113 Possible complications related to it included inadvertent 

intravascular or intraarterial (carotid artery) injection leading to 

central nervous system or cardiovascular toxicity, hemorrhage, 

airway obstruction, allergy, vocal cord paralysis, and mucosal 

sloughing. Peritonsillar infiltration must be performed by a skilled 

clinician who is familiar with the technique. The safest site is just 

underneath the anterior pillar in the mid-portion of the tonsillar 

bed; this corresponds to the farthest distance from the surrounding 

vasculature. 

Suggested Anesthetic Techniques 

How, then, should the child be anesthetized for tonsillectomy? In 

our institution anesthesia is induced with propofol 3 to 5 mg/kg or 

via inhalation with sevoflurane in nitrous oxide and oxygen. 

At induction of anesthesia ondansetron and dexamethasone 

0.15 mg/kg are given intravenously. A small dose of fentanyl 1 to 

2 µg/kg should be given. Airway maintenance should be via a 

reinforced LMA or endotracheal tube. An LMA is contraindicated 

if there is a risk of regurgitation of gastric contents. If tracheal 

intubation is preferred, a neuromuscular blocking agent may be 

administered (e.g., mivacurium 0.1 mg/kg if a spontaneous breathing 

technique is used or atracurium 0.5 mg/kg or vecuronium 0.1 

mg/kg if positive-pressure ventilation is used). Alternatively the 

trachea may be intubated under deep inhalational anesthesia. 

Postoperative analgesia may be administered in the recovery room 

in the form of fentanyl 1 µg/kg. Regular paracetamol (and if no 

contraindications diclofenac) should be prescribed for the 

postoperative period. Oramorph (0.5 mg/kg) should be prescribed 

as required. Maintenance I.V. fluids should be prescribed until the 

child has resumed drinking. 

Children With Obstructive Sleep Apnea 

Children with obstructive sleep apnea frequently have adenotonsillar 

hypertrophy. Enlarged tonsils can cause hypoventilation 

resulting in hypoxia, hypercapnia, acidosis, and pulmonary 

hypertension. Cor pulmonale and cardiac arrhythmias can result. 

It is important to recognize intermittent cyanosis and difficulty in 

rousing these children during the day. 114 Seizures can occur 

secondary to hypoxia. Hypertrophied tonsils must be recognized 

early to avoid cardiac complications. These children may fail to 

thrive and develop facial abnormalities. Pulmonary hypertension 

can be reversed and cardiac enlargement can be relieved by 

emergency tonsillectomy. 114 General anesthesia for children with 

chronic upper airway obstruction secondary to tonsillar hypertrophy 

requires special considerations. There is a risk of death 

from anesthesia in this group without a full preoperative assessment. 

114 The child with suspected OSA may undergo a sleep study 

to determine the extent of the disease. Findings in moderate to 

severe OSA include at least two of the following: 10 or more apneas 

every hour, minimum desaturations below 90%, and transcutaneous 

carbon dioxide measurements elevated 10 to 15 mmHg or more. 

If cardiac decompensation is present, medical treatment is 

advised prior to tonsillectomy. For anesthesia, it is recommended 

that sedative premedication and opioids be avoided as these 

children are exquisitely sensitive to such drugs. A gaseous induction 

is preferred and when a difficult intubation is anticipated. 115 

During induction, airway obstruction is possible. This is usually 

alleviated with continuous positive airway pressure (CPAP) or the 

insertion of an oral airway when depth of anesthesia is sufficient. 

Extubation while they are awake is safest in children with OSA. 

These children are at risk of postoperative apnea and hypoxia. 

Moderate to severe cases should be nursed in a high dependency 

area with supplemental oxygen or CPAP if required. 

Anesthesia for the Management 

of the Bleeding Tonsil: 


Hypovolemia 

Blood loss is difficult to assess and is often underestimated, since 

much of the blood is swallowed and not measureable unless the 

child vomits. In fact, there may be very little blood to see in the 

throat if it is swallowed. Hypovolemia may be somewhat occult, as 

vital signs are often well preserved in these children who often 

have high circulating levels of catecholamines. 

Coagulopathy 

The child may have a previously undiagnosed clotting disorder or 

may have developed a coagulopathy due to hemorrhage. 

Full Stomach 

The child must be considered to have a full stomach of blood. The 

anesthetic technique must protect the airway from regurgitation 

and aspiration of blood from the stomach. 

Recent Anesthetic 

The effects of drugs from the previous general anesthetic and 

drugs given postoperatively may still be providing sedation. This 

should be taken into account when selecting appropriate doses of 

induction agents when taking the child back to the operating 

theater. 

Grade of Anesthetist 

Anesthesia for re-exploration of a bleeding tonsil is challenging 

and difficult. The most senior anesthetist available should 

administer anesthesia in such cases. 


The child must be resuscitated with intravenous fluid before the 

induction of anesthesia. A full blood count and clotting screen


should be performed, and blood should be cross-matched. 

Hemorrhage is rarely so rapid that it cannot be replaced by 

intravenous administration. Anesthesia should not be induced 

until the child is hemodynamically stable. All equipment should 

be checked, and two suckers should be available with wide-bore 

tubing to remove clots. An experienced assistant should be 

present. The choice of technique for induction of anesthesia will 

depend on the preference and familiarity of the anesthetist. The 

goal is to secure the airway by endotracheal intubation without 

the aspiration of blood. Induction of anesthesia will be via one of 

the following methods: 

● 

● 

● 

Rapid sequence induction, cricoid pressure with the child 

supine 

Rapid sequence induction, crocoid pressure with the child headdown 

in the left lateral position. 

Inhalational induction with the child head-down in the left lateral 

position. 

Once the trachea has been intubated, a large-bore nasogastric 

tube should be passed and the stomach drained of blood. At the 

end of the procedure the child should be extubated awake in the 

head-down left lateral position. 

ANESTHESIA FOR THROAT SURGERY 


There are numerous congenital and acquired lesions of the 

pediatric airway. They frequently pose difficult management 

problems in children of all ages, and prompt diagnosis and early 

intervention are essential to decrease morbidity. Airway problems 

may present in children with chronic disease or acutely in the child 

with no history of airway problems. Some children with chronic 

airway disease may present intermittently with severe respiratory 

compromise and require multiple anesthetics for management of 

the disease process. Fiberoptic endoscopy may be used under local 

anesthesia for preoperative assessment of the airway. Laryngomalacia 

and other obstructing lesions above the vocal cord may be 

well visualized. Any surgery to the airway may result in postoperative 

edema and the possibility of airway obstruction. Intravenous 

corticosteroids may be administered prophylactively during surgery 

or nebulized steroids may be given postoperatively. Nebulized 

epinephrine may also be useful in treating postoperative airway 

edema. 

Anesthetic Management of 

Upper Airway Obstruction 

Children with partial airway obstruction may present with 

stridulous breathing. Stridor may occur on inspiration or on 

expiration. The phase of stridor gives a guide to the site of the 

airway obstruction. Inspiratory stridor results from obstruction 

at or above the vocal cords. Expiratory stridor may indicate 

obstruction below the level of the vocal cords. Weakness or 

hoarseness of the voice indicates involvement of the glottis. 

Causes of Upper Airway Obstruction 

Obstruction of the upper airway may manifest acutely or form part 

of a more chronic disease process. The site may be subglottic, 

glottic, supraglottic, or a combination of these. Causes may be congenital 

or acquired. The causes of airway obstruction that may 

require anesthetic intervention are discussed individually. 

Causes of Acute Stridor 

EPIGLOTTITIS: This is fortunately a rarely encountered disease 

today in countries where infants are routinely immunized with 

Hib (Haemophilus influenzae Type B) vaccine. 117,118 In the United 

Kingdom, Hib has considerably declined since the introduction 

of the conjugated H. influenzae Type B vaccine in 1992, although 

isolated vaccine failures do occur. 119 Edema of the epiglottis and 

aryepliglottic folds rapidly develops in epliglottitis and may almost 

obliterate the airway within a few hours. The child is toxic, 

presenting with stridor and dysphagia. The child will be sitting up 

and leaning forward in a characteristic tripod position with his or 

her mouth open and drooling saliva. The onset of symptoms and 

signs is rapid and severe. Urgent tracheal intubation is required to 

avoid complete upper airway obstruction (UAO) and death. It is 

critical that the child not be upset while awake, as this may 

precipitate complete laryngeal obstruction. Intravenous access 

should be obtained once the child is anesthetized since total 

laryngeal obstruction has been described in a case of epiglottitis 

when venipuncture was performed with the patient awake. 118 The 

typical findings on laryngoscopy under anesthesia are a cherry red 

epiglottitis with a median groove, and the laryngeal inlet may not 

be visible. Compressing the chest may result in bubbles at the 

laryngeal inlet to guide intubation. Once upper airway obstruction 

has been relieved by intubation, the child should be admitted to 

the pediatric intensive care unit, where he or she is sedated and 

ventilated. It is imperative that accidental tracheal extubation does 

not occur. Extubation is usually possible in 24 to 48 hours. The 

improvement in the child’s condition will be heralded by a 

resolution of fever and a leak around the tube as edema subsides. 

Before extubation a fiberoptic laryngoscope may be used to view 

the epiglottis and laryngeal inlet. An alternative is to perform 

direct laryngoscopy under general anesthesia. Rarely, pulmonary 

edema may complicate epiglottitis. It occurs typically after tracheal 

intubation and is thought to result from several factors: hypoxia, 

elevated circulating catecholamine, and a disturbed alveolar 

capillary gradient. It responds well to positive-pressure ventilation, 

positive end–expiratory pressure, and diuretics. 

LARYNGOTRACHEOBRONCHITIS: Laryngotracheobronchitis (croup) 

is a common cause of stridor and differential diagnosis for 

epiglottitis. The infection is viral; parainfluenza, influenza, or 

respiratory syncitial viruses are the commonest causes. The child is 

usually 1 to 5 years old and presents with a barking cough and a 

hoarse voice. Boys are more commonly affected than girls. In its 

mild form, the illness may not even prompt the parents to seek 

medical advice. The rate of onset of symptoms and signs is slower 

than for epiglottitis. The child does not usually appear toxic. Some 

children progress to show evidence of respiratory distress with 

tachypnea, nasal flaring, stridor, and suprasternal and intercostal 

recession. The symptoms are almost always worse at night and 

usually progress for 3 to 5 days and then improvement commences. 

Signs of deterioration are tachypnea, worsensing stridor at rest, 

cyanosis, sedation, and more marked suprasternal and intercostal 

recession. Secretions accumulate, inflammation will occur, and 

complete airway obstruction may result. Respiratory compromise 

occurs slowly, and there is usually time to plan intubation 

to prevent airway obstruction. Treatment includes humidified


oxygen, minimal disturbance, and nebulized epinephrine (0.5 mL/ 

kg up to 5 mL of 1:1000) and intubation in cases of UAO. Those 

children that require intubation usually remain intubated for 

several days. Maintenance I.V. fluids are given and nasogastric 

feeding is introduced in the Intensive Care Unit (ICU). There is no 

proven benefit to giving corticosteroids. 

BACTERIAL TRACHEITIS: Bacterial tracheitis usually occurs after 

croup and is a result of staphylococcal infection. Treatment is with 

flucloxacillin I.V. (50 mg/kg/dose) six hourly and intubation may 

be required for a long period. The tracheal mucosa may slough, 

and blockage of the endotracheal tube may occur. 

RETROPHARYNGEAL ABSCESS: A retropharyngeal abscess may be 

a complication of bacterial pharyngitis or pharyngeal trauma. 

Signs include fever, neck stiffness, dyphagia, and drooling. 

Complete airway obstruction may result or the abscess may burst 

into the pharynx, flooding the airway with pus and resulting in 

aspiration. The retropharyngeal abscess displaces the trachea and 

larynx anteriorly, This can be seen on a lateral neck x-ray (Figure 

99–1). Difficult intubation should be anticipated as the abscess 

may distort normal pharyngeal anatomy. 

PERITONSILLAR ANATOMY: Children with a peritonsillar abscess 

(quinsy) may have marked tonsillar hypertrophy and must be 

preoperatively observed for impending total airway obstruction. 

Symptoms and signs are sore throat, drooling, fever, and trismus, 

which may reduce mouth opening. Treatment involves aspiration, 

antibiotics, and surgical exploration. 

FOREIGN BODY: The anesthetic management for removal of an 

inhaled foreign body is discussed separately. 

Figure 99-2. The lateral neck x-ray of a 4-year-old boy with a 

chest infection who presented with acute upper airway obstruction 

requiring emergency tracheal intubation. After resolution 

of the chest infection, several attempts at tracheal extubation 

failed due to recurrent signs of upper airway obstruction. The 

lateral neck x-ray shows localized prevertebral soft-tissue 

swelling just below the vocal cords and a soft-tissue opacity 

(0.75 cm diameter) projected into the trachea. The opacity was 

later diagnosed as a rhabdomyosarcoma of the trachea. Courtesy 

K. Franklin, consultant pediatric radiologist, Derriford Hospital. 

TUMOR: Acute airway obstruction may be the first presentation of 

a tumor in the airway. Malignant tumors such as rhabdomyosarcoma 

of the airway are fortunately rare (Figure 99– 2). Intubation 

may cause disruption of the tumor and seeding into the 

airway. It is possible to intubate a tumor that is polypoid in shape, 

resulting in total airway obstruction. The tumor may be friable 

and, if touched during attempts at tracheal intubation, may bleed 

into the airway. 

Figure 99-1. The lateral neck x-ray of an 11-year-old boy who 

presented with drooling and acute airway obstruction caused by 

a retropharyngeal abscess. The retropharyngeal abscess is seen 

displacing the larynx and trachea anteriorly. Courtesy K. 

Franklin, consultant pediatric radiologist, Derriford Hospital. 

Causes of Chronic Stridor 

LARYNGOMALACIA: Laryngomalacia is the commonest congenital 

cause of stridor. Characteristic signs are stridor on inspiration with 

intercostal and suprasternal recession during inspiration. Marked 

inspiratory stridor results from incomplete maturation of the 

laryngeal cartilages and a tendency for prolapse of one or more of 

the cartilages into the glottis during inspiration. The condition is 

usually self-limiting. As the child grows, the symptoms disappear. 

Endoscopy is useful for diagnosis and to differentiate symptoms 

related to laryngomalacia from those caused by other conditions, 

including mixed breathing and swallowing and sucking difficulties. 

120 Stridor disappears during deep planes of anesthesia 

and returns once the anesthetic is lightened. On endoscopy the 

laryngeal wall is seen to indraw during inspiration. It should be 

noted that 68% of children with severe laryngomalacia have 

gastroesophageal reflux (based on clinical manifestations/pH 

monitoring). 120 Surgical intervention is limited to those children 

with severe manifestations.


TRACHEOBRONCHOMALACIA: Trachoebronchomalacia is a treatable 

cause of UAO. The cause is a defect or absence of cartilaginous 

rings. Stridor is most prominent on expiration. The 

central airways may narrow by more than 75% on exhalation. 121 

Children may present with “dying spells,” cyanosis and wheezing, 

intermittent airway obstruction, recurrent pneumonia, or an 

inability to be extubated. It is an important cause of airway distress 

during infancy, which usually resolves as the airway enlarges. It is 

particularly common in infants who have had a tracheoesophageal 

fistula repair. There are associations with vascular rings and 

hemangiomas causing external compression. Medical therapy is 

by long-term positive end–expiratory pressure or by continuous 

positive-airway pressure via a tracheostomy. Surgical treatment, 

either in addition to or as an alternative to medical treatment, is by 

trachopexy, resection, external splinting, insertion of bronchial 

stents, and tracheobronchoplasty. 

LARYNGOTRACHEAL STENOSIS: Laryngotracheal stenosis can be 

congenital or acquired. Acquired forms are usually a result of longterm 

tracheal intubation, with an incidence of up to 8% in 

intubated children. 122 The commonest site of involvement is 

subglottic. Other causes of acquired subglottic stenosis are high 

tracheostomy, laryngeal burns, external neck trauma, and 

intrinsic/extrinsic tumors. 123 A diagnosis of subglottic stenosis 

should be suspected when extubation fails due to postextubation 

dyspnea or laryngeal stridor. The main components contributing to 

stenosis are pathologies with decreased mucosal perfusion pressure 

and intubating conditions. 122 Children with subglottic stenosis may 

require tracheotomy and subsequent tracheal reconstruction. 

LARYNGEAL PAPILLOMATOSIS: Laryngeal papillomatosis (LP), 

although rare, is the most frequent benign neoplasm of the larynx. 

The papillomata are cauliflower-shaped and frequently numerous. 

Children with LP present with progressive dyspnea, hoarseness, 

and signs and symptoms of respiratory obstruction. Death by 

asphyxiation, although rare, has been reported. 124 Biopsies are 

usually positive for human papilloma virus and malignant 

transformation may occur. Laryngeal papillomatosis is usually 

diagnosed before the child is 5 years old. 125 It frequently recurs; 

the number of recurrences and duration are extremely variable. 

In general the number of recurrences is inversely related to the age 

of onset. 125 LP often regresses around puberty. 

SUBGLOTTIC HEMANGIOMAS: Children with subglottic hemangiomas 

often have a barking cough and crouplike symptoms. 

Cutaneous hemangiomas may be visible on examination. The 

hemangiomas may recur and occasionally multiple anesthetics 

may be required for surgical intervention. 

Specific Anesthetic Concerns for 

Management of Acute Upper 

Airway Obstruction 

Acute upper airway obstruction is a life-threatening condition. 

The goal is to secure the airway by endotracheal intubation and 

prevent total airway obstruction. 

Preoperative Assessment 

The severity of UAO should be assessed. Signs and symptoms may 

vary from mild stridor to the presence of drooling, dysphagia, and 

later dyspnea associated with UAO due to epiglottitis. It is 

important to remember that the presence of agitation in a child 

may be an early sign of hypoxia. 

Grade of Anesthetist 

Acute UAO is a condition from which probably more young 

children have died because of poor medical management than 

from the disease process itself. Anesthesia for UAO is difficult and 

challenging, even in experienced hands. The most senior pediatric 

anesthetist available should administer the anesthetic. 

Equipment and Skilled Assistance 

Before anesthetizing the child, skilled assistance, appropriate 

equipment, and an ENT surgeon capable of performing an emergency 

tracheotomy should be present. The anesthetist should 

check all equipment before induction. A range of tracheal tubes 

down to the smallest size should be available along with several 

laryngoscopes and introducers. An endotracheal tube several sizes 

smaller than normal may be required for intubation. Suction 

should be turned on and immediately at hand. Emergency drugs 

should be prepared in advance and at hand. 

Table 99-3. Causes of Acute and Chronic Stridor 

Infection 

Inhaled foreign 

body 

Laryngeal edema 

Laryngeal spasm 

Allergy 

Tumor 

Acute 

Laryngotracheobronchitis 

Retropharyngeal abscess 

Bacterial tracheitis 

Acute laryngotracheitis 

Peritonsillar abscess 

Diphtheria 

Epiglottitis 

Watermelon seed, peanut 

Traumatic, posttracheal intubation 

Anesthesia 

Angioneurotic edema 

Malignant or benign 

Subglottic 

Glottic 

Supraglottic 

Chronic 

Stenosis 

Foreign body 

Tracheobronchomalacia 

Vascular ring 

Hemangioma 

Laryngeal papillomatosis, web, polyp, foreign 

body, vocal cord paralysis, dislocation of 

cricothyroid/cricoarytenoid cartilage 

Tonsillar hypertrophy 

Laryngomalacia 

Macroglossia 

Cyst (laryngeal, aryepiglottic, thyroglossal, 

lingual)


Position 

Children with UAO may not be able to lie flat. Induction should 

be by inhalation, with the child adopting the position that allows 

him or her to breathe most easily. This may be sitting propped 

upright or leaning forward. 

Slow Induction 

Induction of anesthesia will be slow. It may take some time for 

anesthesia to reach an adequate depth to permit laryngoscopy. 

Continuous Positive Airway Pressure 

During induction, semiocclusion of the bag on a t-piece will 

provide CPAP. This may improve oxygenation and gas exchange. 

Risk of Aspiration 

These children are at increased risk of regurgitation of gastric 

contents due to gastric stasis and distention. 

Risk of Total Obstruction 

Children with airway tumors or space-occupying lesions may 

develop complete airway obstruction during the induction of 

anesthesia. 

Avoidance of Muscle Relaxants 

Tracheal intubation my not be possible either because of difficulty 

in visualizing the larynx or failure to insert a tracheal tube through 

the narrowed lumen of the larynx or trachea. Positive-pressure 

ventilation of the lungs may not be possible or the ability may be 

lost at any time due to the increasing depth of anesthesia. For this 

reason neuromuscular blocking agents should not be administered 

during induction or before tracheal intubation except during an 

emergency. 

Anesthetic Technique for Management 

of Upper Airway Obstruction 

Sedative premedication must be avoided, as it may lead to acute 

airway obstruction and death. An inhalational induction is the 

safest way to anesthetize a child with UAO, especially in the case of 

severe UAO or epiglottitis. The child is anesthetized by inhalation 

of sevoflurane 1 to 8% in oxygen. A nitrous oxide/oxygen mix may 

be used if the child is adequately oxygenated as guided by a pulse 

oximeter. Intravenous access is obtained and an anticholinergic 

(such as atropine 20 µg/kg) may be injected I.V. Once the child is 

anesthetized, nitrous oxide should be discontinued if used and 

the anesthetic continued in 100% oxygen. When the child is 

adequately anesthetized, laryngoscopy should be performed to 

assess the difficulty of tracheal intubation. The laryngeal inlet and 

supraglottic structures may be sprayed with lidocaine (maximum 

4 mg/kg). Tracheal intubation should be attempted when the child 

is in a deep plane of anesthesia. A tracheal tube several sizes smaller 

than usual may be required for successful intubation. A rigid 

bronchoscope may be inserted in the first instance if the airway is 

too narrow to be intubated with a tracheal tube. 

An inhalational technique is employed to ensure that the child 

breathes throughout the procedure, since it may not be possible 

to manually ventilate the lungs. Apnea may still occur during 

induction. If apnea occurs the anesthetist should attempt to 

manually ventilate the lungs with 100% oxygen. If this is unsuccessful, 

immediate laryngoscopy should be performed and the 

trachea should be intubated. Emergency cricothyroidotomy 

should occur if this is unsuccessful (note that if the obstruction is 

subglottic this is not an option). As previously discussed, a muscle 

relaxant should not be administered to a spontaneously breathing 

child until the trachea has been intubated and the adequacy of 

positive-pressure ventilation has been confirmed. Retrograde 

intubation, in skilled hands, has been used to facilitate intubation 

in epiglottitis (NB: this is not suitable for subglottic obstruction). 

Occasionally it may not be possible to pass a tracheal tube; in this 

instance anesthesia should be continued to enable tracheostomy to 

be performed. 

In many countries, sevoflurane has become the agent of choice 

for inhalational induction, replacing the traditional agent halothane. 

Halothane may still be used in some developing countries, 

as the cost of sevoflurane precludes its use. There were initial 

concerns among anesthetists regarding the use of sevoflurane for 

gaseous induction in children with UAO. The perceived benefit of 

halothane over sevoflurane in such cases was its longer duration 

of action. A concern with sevoflurane was that the child might 

lighten too quickly during laryngoscopy. 126 In comparison to 

halothane, sevoflurane has a benign cardiovascular side-effect 

profile and fewer airway complications; it also has a more rapid 

induction time and rapid recovery after anesthesia. 126 

Once the airway has been secured, continuing management will 

depend on the cause of the upper airway obstruction. If the cause 

responds to medical management, for example infection, the child 

should be sedated and transferred to the ICU for appropriate 

treatment, airway management, and ventilation if necessary. If 

the cause requires surgical intervention, for example laryngeal 

papillomatosis, proceed to surgery if the clinical condition of the 

child is satisfactory. If the UAO does not resolve and is not 

amenable to surgery, tracheostomy may be required at a later date. 

The use of the fiberoptic bronchoscope under local anesthesia 

and sedation has been described for the management of epiglottitis. 

127 Use of the fiberoptic bronchoscope allows diagnosis, 

tracheal intubation, and decision making for the optimal time for 

extubation. The bronchoscope may be inserted nasally or orally 

with the child in the sitting position. Oxygen is delivered through 

a nasal tube. Advantages of this technique are the visualization of 

the pharyngeal and laryngeal structures with minimal stimulation 

while allowing the child to remain in an optimal position. 

Intubation, which is always required, is facilitated as the child is 

breathing spontaneously. The expiratory flow blows bubbles of 

saliva that guide the bronchoscope to the glottis. When the 

internal diameter of the endotracheal tube is larger than 4 mm, 

the bronchoscope is used as a guide. When it is less than 4 mm, the 

bronchoscope is inserted into the trachea with a guidewire slipped 

into the operating channel; the bronchoscope is withdrawn leaving 

the guidewire in the trachea and the endotracheal tube is inserted 

over the guidewire. 

The LMA has been used to maintain the airway in children with 

upper airway obstruction. A case report describes the successful 

use of the LMA in a child with tracheal stenosis. 128 Using an LMA 

for airway management in a child with tracheal stenosis avoids the 

insertion of a tracheal tube, which would further reduce the 

internal diameter of the airway with a subsequent increase in 

resistance. 129 Intubation of the trachea may cause edema, which 

may worsen any tracheal stenosis. Using the LMA, the trachea is


not entered and airway damage is unlikely. If the stenosis is located 

in the proximal trachea, the tracheal tube may be difficult to 

position. By contrast, the LMA is easy to position regardless of the 

site of stenosis. Anesthesia can be maintained more safely if the 

child is allowed to breathe spontaneously through the device. 130 

There are several limitations with the use of the LMA in 

children with UAO. Use of the LMA in children with lesions of 

the oropharynx or epiglottis is not recommended. 131 In cases 

where the abnormality is within the larynx itself, attempts to insert 

the LMA correctly are likely to fail. 132 The LMA should not be used 

in children with external compression of the trachea or tracheomalacia 

because it cannot prevent collapse of the trachea. 128,133 

Anesthetic Management for Endoscopy 

ENT endoscopy includes laryngoscopy and bronchoscopy and 

allows access to lesions in the airway for either diagnostic or 

therapeutic purposes. Microlaryngoscopy can be performed with 

or without bronchoscopy. Indications for bronchoscopy include 

stridor, respiratory distress, follow-up endoscopy, tracheostomy 

evaluation, feeding difficulty, hoarseness or weak voice, and the 

suspicion of an airway foreign body. 134 Common airway diagnoses 

confirmed by microlaryngoscopy are laryngomalacia, subglottic 

stenosis, tracheobronchomalacia, and foreign body inhalation. 

Inhaled foreign bodies are removed endoscopically or bronchoscopy 

may be used to remove sputum plugs and reinflate collapsed 

lung segments. Success depends on good teamwork and cooperation 

between the anesthetist and the surgeon. 

OPTIMAL CONDITIONS: The surgeon requires optimal conditions 

to make an accurate diagnosis. The child needs to be still, with no 

episodes of breath-holding, coughing, laryngospasm, or bronchospasm. 

Neonates with stridor present a particularly difficult 

diagnostic problem. The larynx needs to be visualized under 

normal physiologic conditions and during spontaneous respiration. 

This allows the examiner to see the movement of the epiglottis, 

the vocal cords, and the laryngeal walls. 

CONTROL OF SECRETIONS: Secretions may be reduced by the 

administration of an anticholinergic agent such as atropine or 

glycopyrrolate I.V. during induction. This will also reduce the 

incidence of breath-holding, coughing, laryngospasm, and 

bronchospasm. 

ADEQUACY OF OXYGENATION AND VENTILATION: For endoscopy, 

the anesthetic technique chosen should enable adequate 

oxygenation and ventilation to prevent hypoxia and hypercapnia. 

Avoidance of hypoxia is of the upmost importance. Once the child 

is anesthetized, nitrous oxide should be discontinued and the 

anesthetic maintained in 100% oxygen. This will optimize oxygenation 

and provide a reservoir in case airway difficulties are 

encountered. 

PRESENCE OF AIRWAY OBSTRUCTION: Some children undergoing 

endoscopy have mild or moderate airway obstruction. When 

providing anesthesia for these cases, the ongoing potential for 

worsening of any obstruction should be considered throughout. 

AVOIDANCE OF SEDATIVE PREMEDICATION: It is important that 

the child emerge from anesthesia in a predictable and rapid way. 

The surgeon often needs to assess vocal cord movement and 

laryngeal function as the child awakens. Furthermore, any child 

with UAO must be observed until he or she is awake because of 

the risk of developing life-threatening airway obstruction during 

emergence. 

ENDOSCOPES: Endoscopy may be performed using a rigid scope 

or a flexible fiberoptic scope. To be able to provide a good, safe 

anesthetic it is important to have a working knowledge of the 

different types of scope and the benefits and limitations of each. 

The type of bronchoscope that is used will determine the 

anesthetic technique that is chosen for rigid bronchoscopy. 

The flexible fiberoptic scope is ideal for routine diagnostic 

procedures. It can be inserted into a tracheal tube or an LMA using 

a special angle piece that has a swivel attachment and a diaphragm 

seal. If the diameter of the bronchoscope is small compared to the 

internal diameter of the tracheal tube, the child may breathe 

spontaneously. Positive-pressure ventilation may be an alternative. 

Rigid endoscopy may be performed using a rigid laryngoscope, 

or a Negus or Storz bronchoscope. The Storz pediatric bronchoscope, 

equipped with the Hopkins fiberoptic optical telescope, 

is most commonly used for pediatric bronchoscopy. It has superior 

optics and a sidearm to which a t-piece can be attached (Figure 

99–3). With the telescope in place it is a closed system through 

which the child breathes spontaneously or by controlled ventilation. 

In infants controlled ventilation is usually required. If there 

is any respiratory compromise, assisted ventilation is necessary. 

When the optical telescope is in place, it occupies a large 

proportion of the internal diameter of the bronchoscope; this 

results in an increased resistance to gas flow. This is particularly 

true for the small sizes of bronchoscope. Manual ventilation is 

impaired and may result in impaired exhalation, breath stacking, 

gas trapping, and pneumothorax. This may be overcome by 

frequently removing the telescope to allow breathing or ventilation 

through the larger lumen of the bronchoscope. The viewing end 

of the bronchoscope may be occluded once the telescope is 

removed to provide a closed circuit for spontaneous or assisted 

ventilation via the side arm port. Alternatively, a Sanders 

injector 135 may be connected to the side port of the bronchoscope 

to enable jet ventilation (Figure 99–4). Spontaneous or assisted 

ventilation techniques are safer than jet ventilation using the Storz 

bronchoscope. Jet ventilation should not be used except in larger 

children (>40 kg) and is not advocated because of the risk of 

barotrauma. The alternative to the Storz is the Negus bronchoscope. 

The Negus has a tapered shape and is still used by some 

Figure 99-3. Illustration of the anesthetic techniques possible 

using the Storz bronchoscope. A t-piece breathing circuit may 

be attached to the side arm of the bronchoscope for spontaneous 

or controlled ventilation.


the child spontaneously breathing through the LMA. The LMA 

may distort the epiglottis or not permit full inspection; hence 

caution is advised with this technique, particularly in cases of 

laryngomalacia. 132 

Figure 99-4. Illustration of the anesthetic techniques possible 

using the Storz bronchoscope. Alternatively, a Sanders (Venturi) 

ventilator may be attached to a side port of the bronchoscope for 

jet ventilation. 

ENT surgeons, particularly for foreign body removal. In most 

cases the Storz has superseded it. Spontaneous ventilation may 

occur, with anesthetic gases being delivered via the side arm, 

although dilution of inspired gases takes place. Controlled 

ventilation is not possible since it is not a closed system. A Sanders 

injector may be attached and jet ventilation may be used. 

Anesthetic Technique for Microlaryngoscopy 

The child is anesthetized by inhalation of sevoflurane 1 to 8% in 

an oxygen/nitrous oxide mix or 100% oxygen, depending on the 

oxygen saturations of the child. I.V. atropine 10 to 20 µg may be 

administered. When the child is anesthetized, nitrous oxide is 

discontinued and the anesthetic continued in 100% oxygen. When 

the patient is deeply anesthetized, laryngoscopy is performed and 

the laryngeal inlet and glottic structures are sprayed with lidocaine. 

Intubation may be performed via the nasal route and the tube may 

be withdrawn into the nasopharynx before microlaryngoscopy 

when the suspension laryngoscope has been positioned. Alternatively, 

a short tracheal tube may be used as a nasopharyngeal airway 

connected to an anesthetic breathing circuit. Anesthetic gases are 

delivered by insufflation into the nasopharynx throughout the 

procedure. Scavenging of waste anesthetic gases can be achieved 

by inserting a small suction catheter in the mouth. The microscope 

and suspension laryngoscope are positioned, and after inspection 

the child is allowed to wake up and the tip of the laryngoscope is 

left in the vallecula to view cricoarytenoid and vocal cord 

movement. Venturi or Jet ventilation allows an excellent view of 

the larynx when the Venturi needle is clamped onto the suspension 

laryngoscope. The risks of using jet ventilation in these 

circumstances include insufflation of the stomach and vagal 

stimulation. 136 

Care must be taken when using this technique to ensure that 

the Venturi needle does not become displaced into the trachea, 

which may result in barotrauma. Anesthesia may be maintained 

by total intravenous anesthesia during jet ventilation. 

The LMA has been used successfully during diagnostic 

laryngobronchoscopy. 137,138 The LMA is inserted into the pharynx 

and a flexible or 2-mm diameter rigid fiberoptic scope is 

introduced through a bronchoscopy angle piece to visualize the 

glottis and the trachea. The vocal cords may be visualized with 

Anesthetic Technique for Bronchoscopy 

Induction of anesthesia should be by inhalation, as for microlaryngoscopy. 

Judicious local anesthesia to the respiratory tract is 

the key to a smooth anesthetic for endoscopy in combination with 

appropriate depth of anesthesia. The trachea may be intubated 

with an endotracheal tube or the child may breathe spontaneously 

via a face mask or nasopharyngeal airway before bronchoscopy. 

The procedure may be performed using a rigid bronchoscope or 

a fiberoptic flexible scope. Spontaneous ventilation, apneic 

oxygenation, and jet ventilation techniques may be used. The 

technique employed depends upon the preference of the anesthetist, 

and also the type of bronchoscope used. 

SPONTANEOUS VENTILATION: Spontaneous breathing of 2.5 to 

4% sevoflurane in oxygen insufflated into the pharynx via a nasal 

cannula or short tracheal tube used as a nasal airway may be used 

for bronchoscopy. The anesthetist must ensure airway patency at 

all times. One disadvantage of this technique is that the airway is 

not protected from aspiration. In the absence of airway obstruction, 

total intravenous anesthesia may be used in combination 

with topical lidocaine with the child breathing spontaneously. 139 

At the end of the procedure, the child should be turned onto his 

or her left side, breathing oxygen, to recover from anesthesia. 

Alternatively, the trachea may be intubated at the end of the 

procedure and the tube removed when the child is awake. The 

LMA has been used successfully for fiberoptic bronchoscopy 

in infants. 140 Size 1 and 2 LMAs were inserted, through which a 

3.5-mm fiberoptic bronchoscope was introduced. The technique 

allowed excellent airway management and the passage of a larger 

fiberoptic scope with a suction channel for bronchoalveolar lavage 

and better imaging. 

JET VENTILATION: The Venturi injector was introduced by 

Sanders for intermittent positive-pressure ventilation in 1967. 135 

The Venturi effect relies on the pressure drop when a gas passes 

through a narrow orifice. The pressure drop can be used to entrain 

gases; in the case of the injector this gas is room air. The oxygen 

jet at the proximal end of the scope entrains large volumes of room 

air, allowing adequate ventilation while the surgeon works through 

the bronchoscope. The amount of entrained air depends on the 

depth that the bronchoscope is introduced into the trachea. The 

technique usually lowers the FiO 2 

to around 0.3, which could be 

inadequate to maintain oxygenation when the scope is introduced 

below the carina. This may be a major problem in cases where a 

foreign body has caused pneumonia or if the child has an 

underlying lung disease. Additional oxygen may be supplied at a 

rate of 5 L/min via the t-piece of the bronchoscope. This enriches 

the entrained room air with oxygen to produce an overall higher 

FiO 2 

. 141 Anesthesia is maintained using intravenous agents during 

jet ventilation. Suitable techniques include intermittent boluses or 

a continuous infusion of propofol (with or without remifentanil). 

Barotrauma causing tracheal or bronchial damage may result in 

pneumomediastinum, pneumothorax, and surgical emphysema. 136 

A past medical history of prematurity or lung disease may predispose 

to barotrauma. Hemorrhage is usually minor and settles 

spontaneously. Other complications include hypercarbia and


air trapping, leading to diminished venous return and reduction 

in cardiac output. 

HIGH-FREQUENCY JET VENTILATION: High-frequency jet 

ventilation (HFJV) may be performed via a small catheter inserted 

into the child’s trachea. A high-pressure jet of gas flows out of the 

catheter into the trachea for a very short duration, about 0.02 

seconds, and at a very high frequency (10 to 20 Hz). The technique 

allows good surgical access and adequate ventilation of the lungs. 

Barotrauma may be caused by HFJV and end-expiratory pressure 

should be monitored. A jet ventilator must meet established 

standards: the options must be available to measure inspiratory 

pressure as well as end-expiratory pressure and to set appropriate 

alarm limits. Most ventilators have the facility to measure endexpiratory 

pressure and inhibit the next breath until the pressure 

drops to baseline values. An alternative to this is to insert a second 

catheter into the trachea to measure airway pressure. Anesthesia 

for HFJV is provided by total intravenous anesthesia. A clinical 

report describes the successful use of HFJV via a small catheter 

for laryngotracheal resection with end-to-end anastomosis in 

children. 142 The technique was safe and reliable and allowed the 

surgeon good access while protecting the distal tracheobronchial 

tree from aspiration of blood and secretions. There were no 

adverse hemodynamic or ventilatory consequences as a result of 

the HFJV, and good oxygenation was maintained throughout the 

procedure. The authors did note that a major hazard of distal 

HFJV is barotrauma. The surgeon must take great care not to 

obstruct the surgical field, and adequate monitoring of airway 

pressure must be employed. An electronic transducer in modern 

HFJVs provides this and displays end-expiratory airway pressure. 

APNEIC OXYGENATION: The anesthetist may use total intravenous 

anesthesia or an inhalational anesthetic, combined with muscle 

relaxation. The trachea is not intubated, and ventilation is initially 

supplied by bag mask ventilation. A small catheter is passed into 

the trachea and attached to a continuous flow of oxygen. The 

reservoir created maintains oxygenation for short periods of time; 

however, hypercapnia will occur (at rates of up to 0.8 kPa per 

minute). This technique has largely been superseded by others 

described earlier in this section. 

Anesthetic Management of Removal 

of an Inhaled Foreign Body 

The inhalation of a foreign body is potentially a life-threatening 

event. Boys between the ages of 1 and 3 years of age are most at 

risk. 143,144 The most commonly inhaled foreign bodies are organic 

in nature, 143–145 with peanuts at the top of the list. Foreign bodies 

most commonly lodge in the right main bronchus but may also 

be found in the left bronchus or larynx. Foreign bodies larger than 

20 mm tend to be held up in the oropharynx; irregular and 

pointed medium-sized objects are held up in the larynx, while 

smaller objects descend into the bronchi. 146 The most frequent 

symptoms and signs include cough, cyanosis, wheeze, reduced 

breath sounds, choking, dyspnea, and fever. Possibility of an 

inhaled foreign body should be considered in every child 

presenting with respiratory symptoms of sudden onset. 

If the object inhaled is radiopaque, then a chest radiograph 

confirms the diagnosis. Most of the foreign bodies inhaled are, 

however, radiolucent and are not visible on a chest x-ray. In one 

review of tracheobronchial foreign bodies, only 12 out of 225 were 

radiopaque and visible on a chest radiograph. 145 In children who 

inhale organic radiolucent foreign bodies, the chest x-ray changes 

vary according to time from aspiration. 143 If inhalation occurred 

up to 24 hours ago, the chest x-ray may be normal. After 24 hours 

abnormalities are usually present. The commonest findings on 

chest x-ray 24 hours after foreign body inhalation are atelectasis, 

cardiomediastinal shift, unilateral emphysema, or pneumonia. 

A chest x-ray taken at the end of expiration may show a 

hyperexpanded lung on the side of the lesion. Pneumothorax may 

be present. The possibility of a foreign body in the esophagus 

should be considered, as it may produce airway obstruction. A 

foreign body in the postcricoid region or at the level of the aortic 

arch may compress the trachea at sites that are already 

anatomically narrow, producing airway obstruction. 

The timing for foreign body removal may vary from 24 hours 

to several months. Diagnosis is often difficult. The history can 

be unhelpful, clinical signs are sometimes inconsistent, and as 

mentioned earlier, most foreign bodies are radiolucent. 146 One 

must always consider the possibility of an inhaled foreign body in 

the tracheobronchial branches, even in the absence of signs and a 

negative chest x-ray, particularly in children under 3 years old and 

with a suspicious history. 144 Early diagnosis is important to avoid 

serious complications or even death. 

Specific Anesthestic Concerns 

Inhalation of an organic foreign body, particularly a peanut, may 

induce airway hyper-reactivity and bronchial mucosal reaction, 

caused, for example, by the presence of peanut oil. This may result 

in marked airway reactivity under general anesthesia. Slow 

induction of anesthesia, laryngeal or bronchial spasm during 

anesthesia, and fragmentation or impaction of the foreign body 

pose problems during endoscopic removal. Partial obstruction of 

a bronchus may produce a unidirectional valve effect of the 

obstructed lung. Severe hyperinflation of the affected lung may 

result during either spontaneous or controlled ventilation. Simple 

or tension pneumothorax may occur. Laryngeal, tracheal, or 

subglottic mucosal edema may complicate the postoperative 

period after foreign body removal. The use of corticosteroids 

before and after the bronchoscopy markedly decreases the 

incidence of postoperative subglottic edema that would require 

emergency tracheostomy. 144 


The condition of a child who has inhaled a foreign body will 

vary. The child may have few respiratory symptoms and signs or 

may present in respiratory failure. A thorough and detailed 

preoperative assessment of the child is critical. The foreign body 

may be fixed in a bronchus or may be mobile such that complete 

respiratory obstruction is an ongoing risk. 

Sedative premedication must not be administered. The child 

should be anesthetized by inhalational induction and spontaneous 

ventilation should be maintained throughout. If respiratory failure 

is present, spontaneous ventilation may not be adequate to 

maintain oxygenation. Sevoflurane in oxygen or sevoflurane in an 

oxygen nitrous oxide mixture may be used. Nitrous oxide will 

worsen the situation if hyperinflation is present and should not be 

used. Once anesthesia is established, nitrous oxide should be 

discontinued and the anesthetic maintained in oxygen. Once 

intravenous access has been obtained, atropine or glycopyrollate


may be administered. This will assist in drying up any airway 

secretions and may prevent any bradycardia on instrumenting the 

airway. When an adequate depth of anesthesia has been achieved, 

laryngoscopy should be performed and the larynx and trachea 

sprayed with lidocaine. It may take a long time to reach a depth 

of anesthesia sufficient to allow laryngoscopy, particularly if 

significant airway obstruction is present. Great care should be 

taken to allow adequate time for deep anesthesia to be attained 

before attempting laryngoscopy. Allow several minutes to elapse 

after topicalizing the airway before allowing bronchoscopy to 

proceed. It is essential that tracheal intubation does not occur 

before direct bronchoscopy. The number, type, and position of the 

foreign body are largely unknown before bronchoscopy. Intubation 

may dislodge, impact, fragment and disperse the foreign body 

and may result in total airway obstruction. 

Once the foreign body has been removed, an LMA or tracheal 

tube may be inserted to maintain the airway, the anesthetic 

discontinued, and 100% oxygen administered. The child is 

observed until awake and the tracheal tube may be removed. 

Alternatively, the child may be administered oxygen via a face 

mask until he or she is awake. Glottic edema may result from 

repeated attempts to remove the foreign body, particularly if the 

procedure is difficult or the foreign body fragments or disperses 

into the airway. Airway edema is a significant risk if the foreign 

body is a peanut, as the oil from the nut may cause a chemical 

pneumonitis. Airway edema is treated with humidified oxygen 

and nebulized epinephrine (0.5 mL/kg of 1:1000). Relief may be 

dramatic after nebulized epinephrine but it will be short-lived. 

Additional nebulized epinephrine may be required at regular 

intervals. Systemic corticosteroids should be administered: I.V. 

dexamethasone 0.25 mg/kg on induction and 0.1 mg/kg 6 hourly 

postoperatively. The child should have a postoperative chest x-ray. 

Anesthetic Management for 

Endoscopic Laser Surgery 

Indications 

Laser surgery is frequently used for resection of lesions of the 

larynx and trachea. Common disorders treated with laser therapy 

are laryngomalacia, subglottic hemangiomas, laryngeal papillomatosis, 

and laryngotracheal stenosis. 

LARYNGOMALACIA: Endoscopic resection of the aryepiglottic 

folds, with or without the use of laser, results in rapid improvement 

of both swallowing and ventilation in children with severe 

laryngomalacia. 120 

SUBGLOTTIC HEMANGIOMAS: Subglottic hemangiomas are 

diagnosed endoscopically and are treated by laser destruction. 

Children with subglottic hemangiomas may have recurrent disease. 

LARYNGEAL PAPILLOMATOSIS: Laser surgery is now the mainstay 

of management of LP and is superior to conventional surgical 

removal. 147 Children with LP present for repeat laryngoscopy and 

laser therapy. Complications of the laser treatment of recurrent LP 

in children include laryngospasm, failure of tracheal intubation, 

seeding of papillomata into the distal airway, laryngeal and 

tracheal scarring, and the development of glottic webs. 148 

LARYNGOTRACHEAL STENOSIS: Laser may be effective in the 

treatment of tracheal obstruction caused by granulation tissue or 

stenosis. Use of the flexible fiberoptic laser, in combination with 

the standard pediatric rigid bronchoscope equipment, has been 

described. It provides excellent visualization and well-maintained 

ventilation (assisted or spontaneous) with few complications. 149 


Endoscopic laser surgery requires several modifications to work 

with the anesthetic technique as a result of the presence of the 

lesion and the use of the laser. 

RELATED TO THE LESION: Children who have space-occupying 

lesions of the larynx or trachea may develop acute airway 

obstruction during induction of anesthesia. Intubation may not 

be possible, either because of difficulty in visualizing the larynx 

or failure to insert a tracheal tube because of a narrowed trachea 

or larynx. Controlled ventilation of the lungs may not be possible 

or the ability to can be lost at any time with increasing depth of 

anesthesia or following the administration of a muscle relaxant. 

There is an additional risk of disrupting a lesion and seeding it 

farther down the trachea. The lesion may impact the lumen of the 

tracheal tube. 

RELATED TO THE LASER: The carbon dioxide laser (wavelength 

10,600 nm) is used in ENT for coagulation and precise surgical 

cutting. 

LASER FIRES: An airway fire is perhaps the worst complication in 

ENT anesthesia. They are not uncommon, with an incidence of 

between 0.4 and 1.5%. 150 The laser may ignite anesthetic gases 

or silicone, rubber or PVC tubes, gauze swabs, or drapes. It is 

imperative that all precautions be taken to avoid this disastrous 

complication, and systems are in place to cope with a fire should 

it occur. 151,152 If ignition occurs, the oxygen source should be 

disconnected and the operative site sprayed with water. 

LASER TUBES: If tracheal intubation is performed, a specially 

designed laser tube should be used. Standard tubes may be adapted 

for laser use by wrapping them in foil. Special laser tubes are 

metallic-coated tubes, tubes coated with a substance to absorb and 

diffuse any incident laser energy and flexible metallic tubes without 

cuffs. The tip and the cuff of laser tubes are flammable, although 

this is unlikely since the cuff is filled with saline and protected with 

moistened gauze packs. There are other considerations when using 

laser tubes. 129 The wall of a special laser tube is thicker than that of 

a standard tube; as a consequence of this, resistance to gas flow is 

higher. This is of particular concern when using the smaller sizes 

of laser tube. Higher ventilation pressures may be necessary. Laser 

tubes can absorb or reflect laser energy in different ways and can 

cause unintended and accidental burns of surrounding tissues. 

ANESTHETIC GASES: Regular PVC tubes wrapped in foil are 

occasionally still used to reduce cost (this practice is not 

recommended by the authors). These tubes may be readily ignited 

by a focused laser during ventilation with high inspired oxygen 

concentrations or oxygen/nitrous oxide mixtures. As a rule nitrous 

oxide should not be used during laser surgery; nonexplosive 

mixtures of oxygen and air should be used, keeping the total 

inspired oxygen concentration to less than 40%. 153 

EYE PROTECTION: Operating theater staff and the eyes of the child 

should be protected at all times when a laser is used. All staff 

should wear goggles to absorb energy from the laser, and the doors


of the OR should be locked to prevent other staff from wandering 

in. Signs should be clearly displayed to warn all staff outside of the 

OR that the laser is being used. 

LASER SURGICAL PLUME: The smoke or plume from laser surgery 

has been shown to contain a variety of hazardous toxic chemicals, 

some of which are known to be carcinogenic. 154 Viral DNA has 

been isolated in laser surgical plume. 155,156 The entire surgical team 

should be provided with face masks capable of filtering particle 

sizes of 0.5 µm. Devices to scavenge the smoke from the operative 

sight should be used. 


As with all shared airway surgery, good communication between 

the surgeon and anesthetist is of paramount importance. The main 

surgical requirements are a stationary target without obstruction 

of the surgeon’s view or the laser. 157 In the child with signs or 

symptoms of acute airway obstruction the emergency anesthetic 

management will be as described earlier in the chapter. Children 

with chronic airway obstruction scheduled for endoscopic laser 

surgery may be anesthetized using a number of different techniques. 

Methods include spontaneous ventilation using a nasal 

airway, controlled ventilation using a nasotracheal tube, jet 

ventilation using a Sanders injector, HFJV, and intermittent 

apnea. 158 

SPONTANEOUS VENTILATION: Spontaneous breathing of a volatile 

agent in oxygen insufflated into the pharynx via a short nasal 

endotracheal tube may be easy in skilled hands. 159 The anesthetist 

must ensure that the airway is patent at all times. The safety of this 

technique relies heavily on the early detection of impending 

airway obstruction. 160 Disadvantages of this technique are that the 

airway is not protected from aspiration and the inspired gases 

must be adjusted so that they will not support combustion (see 

earlier). Suitable volatile agents include sevoflurane. Alternatively 

total intravenous anesthesia may be used. Laser resection of a 

lesion in the airway usually produces marked improvement in 

airway patency and in the majority of cases intubation is not 

required afterward. 

TRACHEAL INTUBATION: The most widely adopted technique for 

microlaryngeal surgery is probably tracheal intubation, using a 

laser tube of a smaller size than usual when possible. It protects 

the airway and enables controlled ventilation. There are, however, 

several disadvantages to this technique. 161–163 Surgical access to 

certain lesions may be limited. There is an impeded view of the 

interior of the larynx, decreased space for surgical manipulations, 

tissues may be distorted, and the presence of a potentially 

flammable substance close to the laser increases the risk of an 

airway fire. Spontaneous ventilation is unsuitable for endoscopic 

laser surgery because aspiration of blood or debris may occur at 

any time and the immobility of the laryngeal field cannot be 

guaranteed. 164 Neuromuscular paralysis is considered essential 

when using the laser to avoid accidental damage to healthy 

tissue. 152 Thus, muscle relaxation and controlled ventilation are 

preferred. Ventilation through a tracheal tube should generally be 

the technique of choice, although it may not be for reasons 

discussed earlier. Surgical access to all areas of the glottis and 

subglottis is challenging, however small the tracheal tube. 165 It may 

not be possible to use this technique in infants who already have 

a narrowed tracheal inlet. 136 

APNEA: Apnea provides optimal conditions for laser surgery to 

the larynx and trachea since the tissues are immobile. Anesthesia 

may be induced via an inhalational or intravenous route combined 

with neuromuscular blockade. The trachea is not intubated, and 

ventilation is provided by bag and mask. Intermittent apnea allows 

the surgeon to operate in an unobstructed field between periods 

of ventilation by the anesthetist. Hypercapnia and hypoxia may 

occur. The procedure may be lengthy, as this technique requires 

frequent interruptions in operating. The trachea is not intubated 

and, thus, is not protected from the aspiration of blood, debris, 

smoke, and gastric contents. 

JET (VENTURI) VENTILATION: For a full description of jet 

ventilation, see earlier. There are several advantages to using jet 

ventilation for laser surgery in the larynx or trachea. It provides an 

optimal surgical view and access and allows use of the laser 

without risk or time limitation. The anesthetic technique avoids 

tracheal intubation; thus, the airway is not protected from tracheal 

aspiration. A disadvantage of jet ventilation is that particulate 

debris may be disseminated into the lung or into the operating 

theater. Contamination can be minimized by interruption of 

ventilation during activation of the laser. 152 If inhalational anesthesia 

is used for maintenance, pollution of the OR may occur. 

Total intravenous anesthesia is a better alternative. Methods of 

tubeless anesthesia used are distal and proximal jet ventilation. 

Supralaryngeal jet ventilation provides superb visualization and 

access to the larynx. When delivered via an all metal tube, a 

bronchoscope, or cannula and laryngoscope, there is no organic 

combustible material in the surgical field, making supraglottic 

Venturi jet ventilation a safe and effective technique for laser 

surgery on the airway. 162 

HIGH-FREQUENCY JET VENTILATION: This technique allows 

excellent surgical access. It is performed by inserting a small 

catheter into the trachea. A low inspired concentration of oxygen 

is delivered without nitrous oxide to reduce the risk of conflagration. 

163 The inherent positive end-expiratory pressure 

developed may reduce the risk of aspiration into the lungs. 164 A 

central venous catheter shielded from the laser using metal tape 

has been used as a conduit for HFJV in children. 158 If a multilumen 

catheter is used the distal lumen can be used to deliver ventilation 

and the middle lumen to monitor airway pressure. Even with foil 

wrapping, the external diameter of the catheter is less than 

2.5 mm; the flexible nature of the line enables the surgeon to move 

it into the position that allows the best surgical access. The catheter 

may be left in situ and ventilation continued until the child is 

recovered from neuromuscular paralysis or other agents and is 

awake and breathing adequately. 

Percutaneous transtracheal high-frequency jet ventilation 

(TTJV) has been described for endoscopic laser surgery in 

children with severe obstructive lesions (>70%) of the lumen 

of the trachea and or larynx. 164 The catheter is inserted under 

direct bronchoscopic vision. TTJV offers many advantages for 

microlaryngoscopic laser surgery. 164 The absence of a tracheal tube 

allows excellent vision of the operative field, profound neuromuscular 

paralysis is possible if required, adequate gas exchange may 

be maintained; and the potential for airway trauma and an airway 

fire in the presence of an endotracheal tube is eliminated. Control 

of the airway is possible and the risk of aspiration of blood and 

debris is minimized by the continuous expiratory flux. 169 Surgery 

may proceed without being impeded by airway equipment. 

Complications observed with this technique (all of which resolved


with appropriate treatment) included surgical emphysema, pneumothorax, 

and cardiovascular depression due to vagal stimulation. 

However, this technique has allowed procedures that would have 

otherwise required formal tracheostomy to be performed safely. 

Because this technique is more invasive than orotracheal intubation, 

it should be reserved for selected difficult cases, such as 

severe upper airway stenosis. It should not be used as a routine 

technique in pediatric endoscopic surgery and should only be 

performed by experienced practitioners in specialized centers. 164 

ANESTHETIC MANAGEMENT 

FOR LARYNGOTRACHEOPLASTY 


Laryngotracheoplasty is performed to relieve subglottic stenosis. 

It is the definitive treatment for subglottic stenosis and the original 

procedure was first performed in 1974. 170 A castellated incision is 

made in the larynx and upper trachea, the subglottic region is 

entered and scar tissue excised. A stent is placed in the glottis, 

subglottis, and upper trachea to guide the mucosa during the 

healing process, and segments of cartilage are sutured together in 

a distracted position. The stent is removed via a bronchoscope 

6 weeks later. A costal cartilage graft for laryngotracheal reconstruction 

has also been described. 171 A midline cartilaginous 

incision is made from below the vocal cords to the tracheotomy. 

The lumen is entered by dividing the mucosa, but the scar tissue 

is left undisturbed. Placing the costal cartilage graft between the 

cut edges widens the lumen of the trachea, and a stent is not 

required. A modified anterior cricoid split procedure has also been 

described. 172 Not all cases of subglottic stenosis necessitating 

tracheotomy require a laryngotracheoplasty. Other simpler 

surgical procedures may be performed endoscopically: removal 

of scar tissue, dilation of the stenosis, laser excision of scar tissue, 

insertion of stent, and intralesional injection of steroid. 173 


Children listed for a laryngotracheoplasty will already have a 

tracheostomy. Sedative premedication may be safely administered 

if required. Anesthesia may be induced via an inhalational or 

intravenous route. Once intravenous access has been gained, an 

opioid or muscle relaxant can be administered; the choice depends 

upon the preference of the anesthetist. The glottis should be 

sprayed with lidocaine (4 mg/kg maximum dose). Maintenance is 

by propofol infusion or by inhalation. A cuffed tracheal tube or 

tracheostomy tube is used intraoperatively if possible. This 

facilitates good ventilatory control throughout the procedure and 

protects the airway from soiling with blood or debris. An armored 

flexible tube may be used, although its thicker wall compared with 

standard tracheal tubes may preclude its use in small children. The 

tracheal connector used must be small and neat and not intrude 

into the surgical field. To allow good surgical access, the neck is 

extended and a sandbag is placed between the scapulae. Standard 

monitoring as described in the introduction should be used. 

Particular attention should be directed toward airway pressure as 

it is possible for the tracheal tube to become kinked or block and 

tracheal suction may be required intraoperatively. Fluids should be 

administered as required. A nasogastric tube should be passed, as 

swallowing may be impaired in the initial postoperative period. 

At the end of surgery any neuromuscular blocking agent should be 

reversed and the child allowed to awaken with the tracheostomy 

in place. Humidified oxygen should be prescribed postoperatively 

and the tracheostomy should be suctioned regularly. If a costal 

cartilage graft has been taken a chest x-ray should be taken to 

exclude pneumothorax. 

ANESTHETIC MANAGEMENT 

FOR TRACHEOTOMY 

Indications 

Tracheotomy may be performed to relieve emergency airway 

obstruction when tracheal intubation is not feasible, to relieve 

chronic UAO, or to facilitate mechanical ventilation outside the 

critical care unit in children with severe chronic respiratory 

disease. 

There are a number of serious complications of tracheostomy 

that may be divided into those that occur early and those that are 

manifested later. Early complications include pneumothorax, 

bleeding, pneumomediastinum, and the development of surgical 

emphysema. The tracheostomy may become obstructed, or a false 

passage may occur, or the child may be accidently decannulated. 

Complications that occur later include infection, erosion of the 

skin by the tapes, the development of tracheal strictures, granulomata, 

and fistulas. The severity and magnitude of the complications 

related to tracheostomy make the procedure one of 

substantial risk. It should, if possible, be avoided at all costs in 

children. There is no “cut-off ” for the duration of endotracheal 

intubation before proceeding to tracheostomy. Tracheal intubation 

may continue for many weeks if not months if the disease process 

requiring artificial ventilation is not likely to resolve. 


The anesthetic technique for the management of acute UAO 

requiring tracheostomy has already been described. Most children 

scheduled for tracheostomy are already intubated; the anesthetic 

technique for these children is discussed in this section. Sedative 

premedication may be administered if the child is awake. 

Alternatively if the child is sedated and intubated, sedation may be 

increased for transfer to the OR. On arrival in the anesthesia room, 

an inhalational anaesthetic may be commenced, for example 

sevoflurane or isoflurane in 100% oxygen. Alternatively, a propofol 

infusion can be used. Employing the use of 100% oxygen and 

increasing the minute volume will optimize oxygenation in case of 

surgical difficulties. A neuromuscular blocking agent and an opioid 

should be administered. The child is positioned with a sandbag 

underneath the shoulders with the neck extended to bring the 

trachea into view. Local anaesthetic with epinephrine may be 

infiltrated. Tracheostomy in children is performed by making a 

vertical incision in the second and third tracheal rings. A high 

approach is avoided, as this is associated with an increased 

incidence of tracheal stenosis. A stay suture is inserted on each side 

of the tracheal incision and left in place postoperatively to allow 

the orifice to be opened in the event of postoperative difficulties. 

Cartilage is never removed during surgery, as this would weaken 

the trachea, encouraging it to collapse or stenose. 

A fiberoptic bronchoscope may be inserted through the 

tracheal tube to facilitate accurate placement of the tracheostomy.


Alternatively, a rigid bronchoscope may be used. This enables 

adequate ventilation; it stabilizes the trachea and permits direct 

surveillance and guidance of the procedure. The endotracheal 

tube must be withdrawn but not removed when the tracheostomy 

tube is inserted. Only when adequate ventilation through the 

tracheostomy has been confirmed should the tube be removed. 

Fiberoptic confirmation through the tracheostomy tube should 

then be performed. The tracheostomy tube should 0.5 mm larger 

than the tracheal tube, since the site of entry is subglottic. Once the 

tracheostomy is in situ, a sterile connector is used to connect it to 

the anesthetic breathing system. At the end of the procedure a tie 

is inserted into each side of the tracheostomy tube and tied around 

the neck. The child is allowed to emerge from anesthesia if 

appropriate or transferred back to the CCU sedated and ventilated. 

Very occasionally the surgeon may suture the wings of the 

tracheostomy in place to prevent accidental decannulation in the 

early postoperative period. 

Supplemental humidified oxygen should be provided postoperatively, 

since the natural humidification provided by the upper 

airway has been bypassed. The tracheostomy should be regularly 

suctioned initially every 15 to 30 minutes to maintain a clear 

airway and then less frequently, depending on clinical condition. 

Preoxygenation should be performed before suctioning to prevent 

desaturation. A chest x-ray should be obtained in recovery to 

check the position of the tracheostomy tube and exclude 

pneumothorax. The child should be nursed under constant supervision 

until the tracheostomy tract has formed, which usually 

takes 7 to 9 days. 

CONCLUSION 

In this chapter we have discussed the specific anesthetic concerns 

and the techniques used in managing anesthesia for a wide variety 

of surgical procedures on the ear, nose, and throat. Where 

appropriate, details of the surgical procedure have been included 

for completeness. This chapter has described some of the 

challenges faced by the anesthetist for ENT surgical procedures. 

Some require the airway to be shared, some require exacting 

operative conditions, and others require the emergency management 

of difficult airways. The evolution of anesthetic agents and 

devices has greatly increased the range of techniques available to 

the ENT anesthetist. The increasing indications for fiberoptic 

endoscopy and laser surgery have further increased the variety of 

ENT procedures for which anesthesia is required. In summary, 

anesthesia for ENT surgery is fascinating, varied, and continually 

developing as new surgical procedures and techniques are 

introduced. 

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