Pediatric Tonsillectomy and Adenoidectomy Procedures

DECEMBER 1995, VOL 62, NO 6

Home Study Program PEDIATRIC TONSILLECTOMY AND ADENOIDECTOMY PROCEDURES

T

he article “Pediatric tonsillectomy and adenoidectomy procedures” is the basis for this AORN Journal independent study. The behavioral objectives and examination for this program were prepared by Janet S. West, RN, BSN, CNOR, clinical editor, with consultation from Susan Bakewell, RN, MS(N), professional education specialist, Center for Perioperative Education. A minimum score of 70% on the multiple-choice examination is necessary to earn three contact hours for this independent study. Participants receive feedback on incorrect answers. Each applicant who successfully completes this study will receive a certificate of completion. The deadline for submitting this study is May 31, 1996. Send the completed application form, multiple-choice examination, learner evaluation, and appropriate fee to AORN Customer Service c/o Home Study Program 2 I70 S Parker Rd, Suite 300 Denver, CO 80231-5711

BEHAVIORAL OBJECTIVES

After reading and studying the article on pediatric tonsillectomy and adenoidectomy (T&A) procedures, the nurse will be able to ( I ) discuss the diagnostic and surgical indications for T&A procedures, ( 2 ) describe the recommended perioperative care for pediatric patients undergoing T&A procedures, (3) discuss equipment preparation and surgical setup for pediatric patients undergoing T&A procedures, and (4) discuss perioperative nurses’ roles when caring for pediatric patients undergoing T&A procedures.

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Pediatric Tonsillectomy and Adenoidectomy Procedures onsillectomy and adenoidectomy (T&A) procedures are the most prevalent major surgery performed on children of all ages in the United States. Today, T&A procedures rank 24th in frequency among all elective surgeries performed. Removal of the tonsils and adenoids has been described by some authors as an American ntual. Nearly one third of the children in the United States have their tonsils and adenoids removed; however, less than 5% of children have adequate medical indications for T&A procedures.' HISTORICAL BACKGROUND

Tonsillectomy procedures are among the oldest surgical procedures still in existence. Surgical removal of tonsils appears to have been performed for at least 3,000 years. Descriptions of tonsillectomies appear about 1000 BC in Hindu literature.' Augustus Celsus, a Latin author of medical and surgical literature, described a technique used for removal of tonsils as early as 50 AD.3 The earliest adenoidectomy procedures probably were undertalen in the latter half of the 19th century. The two surgical procedures were combined early in the 20th century as a cure for numerous disorders including rheumatism, poor appetite,

unexplained fevers, asthma, allergic rhinitis, mental retardation, enuresis (ie, bed wetting), and halitosis, as well as recurrent pharyngitis. Tonsillectomy procedures on entire populations of school children were performed during the second and third decades of this century. The frequency of T&A procedures has been reduced drastically since the advent of antibiotic^.^ In addition, the publication of well-controlled clinical trials during the last 20 years has enabled otorhinolaryngologists to better select pediatric surgical patients who will benefit from T&A procedures.s Recent clinical trials have resulted in an overall decline in T&A procedures for recurrent infections and an increase in T & A procedures for management of upper airway obstructions. Ongoing clinical investigations continue to redefine selection criteria for pediatric surgical patients undergoing T&A procedures. INDICATIONS FOR TONSILLECTOMY

Tonsils (ie, faucial tonsils) are paired masses of lymphoid tissue located on the lateral walls of the oropharynx. Otorhinolaryngologists perform tonsillectomy procedures with or without adenoidectomies to treat lymphoid hypertrophy resulting in upper airway obstructions and recurrent or chronic infections (ie, tonsillitis, adenoiditis, otitis media). Other A B S T R A C T The most common pediatric surgical procedures performed in indications for surgical removal the United States today are tonsillectomies and adenoidectomies of the tonsils andlor the adenoids (T&A). Surgical team members must be highly trained and efficient include tonsillar abscess (ie, quinto ensure optimal patient outcomes, reduce surgical costs, and cy), cor pulmonale (ie, secondary decrease the risks and potential complications inherent in T&A pro- to adenotonsillar hypertrophy), cedures. The authors review current surgical indications for T&A pro- dysphagia with ingestion of solid cedures: recommended preoperative, intraoperative, and postopera- food, speech abnormalities, orthotive patient care; and the management of potential complications. dontic complications, and suspicion of malignancy. AORN J 62 (Dec 1995) 887-904.

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Upper airway obstructions. The most common indication for T&A procedures is adenotonsillar hypcrplasia that results in an obstructive sleep disorder ( O S D ) or upper airway resistance syndrome (UARS).I' In children without adenotonsillar hyperplasia, upper airway resistance increases during sleep because of a decrease in the inuacle tone of the upper airway. In patients with OSD, this incrcase in resistance is exaggerated, most often by hyperplasia of the tonsils and adenoids, resulting in various degrees of upper airway obstruction. Obstructive adenotonsillar hyperplasia often occ~irsin the tonsils and adenoids simultaneously, necessitating the removal of these tissues at the same time. In general, the adenoids may be enlarged with only moderate tonsillar hypcrplasia in children undcr seven years of age. In children seven years of age or older, tonsillar hyperplasia may be present with only mild to moderate adenoid hyperplasia. Children with congenital craniofacial abnormalities (eg, Down's syndrome) havc a lesser degree of adenotonsillar hypcrplasia that may result in clinically significant airway obstructions. Po/~snnirio,~i.aplIv. The diagnosis of OSD is confirmed by a sleep study (ie, polysomnography). This is performed ideally as an overnight, niultichannel recording of nocturnal respirations including measurements of nasal and oral airtlows, respiratory effort, and oxygen saturation, ;IS well its electroence p h a 1o g r a p h y (EEG ) and e 1e c t r o c a rd i o g rap h y (ECG). Polysomnography is an expensive and timeconsuming test that otorhinolaryngologists usually rescrve for children who are difficult to diagnose or for whom the risk of surgery is unusually high. Other diogizostii, tests. Audiotaping or videotaping children's respirations during sleep may be an alternative method for diagnosing OSD. Lateral neck x-rays and cephalomctric (eg, lateral head) films occasionally can be helpful in identifying thc level of upper airway obstruction. Likewise, flexible fiberoptic nasopharyngoscopy can help otorhinolaryngologists determine the degree of adenotonsillar hyperplasia that results in OSD or UARS. Otorhinolaryngologists physically examine children's tonsils by placing two tongue depressors on the anterior two thirds of children's tongues (ie, in front of the circumvallate papillae to reduce gagging and medial displacement of the tonsils). A standardized system for evaluation of tonsillar size is shown in Figure 1. Recurrent acute or chronic tonsillitis. Recurrent acute or chronic bouts of tocsillitis unresponsive

Figure 1 A standardized system for evaluation of tonsillar size. (Reprinted from Pediatric Clinics of North America 36 [December 19891, L Brodsky, with permission from W B Sounders, Co, Philadelphia)

to appropriate medical inanagement may warrant removal of the tonsils. Medical management includes prolonged courses of antibiotics (eg, penicillin, cephalosporin) and daily throat irrigations. Infections of the tonsils for which tonsillectomy procedures are indicated are divided into two categories: recurrent acute and chronic tonsillitis. R i w i w n f m ~ r tonsiUitis. e Recurrent acute tonsillitis is defined as six or more episodes of acute tonsillitis in one year, four or more episodes per year for two years, or three or more episodes per year for three years.' Typical symptoms of recurrent acute tonsillitis include sorc throat, dysphagia, fcver, tender cervical lymph nodes, and erythema and/or exudates on the tonsils. Secondary symptoms (eg, headache, nausea, decreased appetite, abdominal discomfort) also may be present. The most common etiology of recurrent acute tonsillitis is group A beta-hemolytic streptococci (GABHS).XWhen these bacteria are noted on throat cultures or rapid strep (ie, streptococcus) screens, administration of penicillin or cephalosporin antibiotics is warranted." Other bacteria, which usually are pathogenic elsewhere in the upper aerodigestive tract, also may cause recurrent acute and chronic tonsillitis. These organisms include Streptococcus pneunionior, Stuphylocwrus U U I - ~ M S and . Haemophilus influenza. I('

Chronic, tonsi/litis. Chronic tonsillitis is defined as a persistent bout of tonsillitis lasting 10 weeks or longcr despite at least three different courses of 888

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Table 1 antibiotics including those specific against beta-lactamase-producing microorganisms. The streptococcal carrier state, in which cultures are persistently positive for GABHS in the absence of symptoms and despite medical therapy, also is considered an indication for surgery." Table I summarizes the surgical indications for tonsillectomy. Anaerobic bacteria as well as viruses may be found deep within the tonsillar tissues. Actinomyces mycoplasina and chlamydia frequently are cultured from core tonsil tissue and may be associated with tonsillar hyperplasia.I2 The most common viral cause of recurrent acute or chronic tonsillitis is the EpsteinBarr virus, which most often is associated with mononu~leosis.~~ The emergence of resistant strains of GABHS, beta-lactamase-producing organisms, and encapsulated anaerobes all contribute to medical failures in the treatment of tonsillitis. INDICATIONSFOR ADENOIDECTOMY

The adenoids (ie, nasopharyngeal tonsil) are composed of lymphoid tissue and are situated on the posterior wall of the nasopharynx. As a result of their position adjacent to both the nasal cavity and the eustachian tube orifice, adenoid hyperplasia plays a significant role in obstructive adenotonsillar hyperplasia, recurrent acute or chronic pharyngeal infections, and recurrent otitis media or otitis media with effusion. Adenoid hypertrophy with upper airway and eustachian tube obstructions and recurrent or chronic infections (ie, adenoiditis, otitis media) are indications for adenoidectomy procedures. Signs and symptoms. The presence of chronic mouth breathing, snoring, hyponasal speech, and the classic adenoid face (ie, open mouth, dull appearance, elongated face, dark circles under the eyes) suggests adenoid hyperplasia. The child eventually may show effects of nocturnal respiratory insufficiency (eg, intercostal retractions, nasal flaring) that can lead to pulmonary hypertension and cor pulm0na1e.I~Children with a history of recurrent or persistent rhinorrhea, postnasal drip, chronic cough, and halitosis also should be suspected as having chronic adenoiditis. Otitis media. Recurrent acute or chronic otitis media may be associated with infected, hypertrophied adenoids and the mechanical or functional blockage of eustachian tube orifices or be related to bacteria ascending the eustachian tubes from the adenoid masses.lSChronic otitis media can lead to fluctuating conductive hearing loss that is reversible

INDICATIONS FOR TONSILLECTOMY'

Infection Recurrent streptococcal tonsillitis despite appropriate medical therapy Recurrent acute tonsillitis complicated by peritonsillar abscesses, abscessed lymph nodes, acute airway obstructions, and/or febrile seizures Persistent pathogenic streptococcal carrier state nonresponsive to appropriate medical therapy Chronic streptococcal or nonstreptococcal pharyngitis Chronic intermittent sore throat not attributable solely to other causes

Upper airway obstruction not associated with other causes 0

Sleep apnea and/or severe sleep disturbances

0

Cor pulmonale not attributable solely to other causes

0

Failure to thrive not attributable solely to other causes

0

Eating or swallowing disorders not attributable solely to other causes

0

Obligate mouth breathing not attributable to other causes

0

Speech abnormalities not attributable to other causes

Uooer airwav obstruction associated with other causes ~~

Congenital craniofacial abnormalities Dental growth abnormalities 0

Cardiac disease exacerbated by upper airway obstruction

Other

Suspected tonsillar tissue malignancy

* Adapted from the guidelines of the American Academy of Otolaryngology-Head and Neck Surgery, Pediatric Otolaryngology Subcommittee.

with treatment. Children with recurrent acute or chronic otitis media who are undergoing insertion of second sets of tympanostvrny tuba also may benefit from adenoidectomy procedures, regardless of the size of the adenoids.lh Sinusitis. Stasis of nasal secretions from adenoid hyperplasia can lead to sinusitis.'7 Children with allergic rhinitis and chronic sinusitis, however, may be confused with those with chronic and recurrent adenoiditis, although they are less likely to snore or have other symptoms of obstructive hyperplasia. Adenoidectomy also is advocated in young children with chronic sinusitis before they are considered for 889

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Table 2 extensive functional endoscopic sinus surgery. I x Diagnosis. Direct visualization of abnormal adenoid tissue inasses by nasopharyngoscopy or anterior rh i n o s c o p y c o n f i r m s adenoid h y p e rpl a s i a . I n nasopharyngoscopy, a small flexible scope with fiber-optic lighting is inserted through the nostrils to visualize the adenoi In anterior rhinoscopy, light is reflected on a hand rror for the purpose of cvaluating the child's nasal mucosa. turbinates, and septum. Assessment of the palate is extremely important in the evaluation of the adenoids. If an occult submucous cleft palate is present and not recognized before an adenoidectomy, postoperative hypernasal speech and velopharyngeal insufficiency can result. The presence of a bifid uvula, fluid regurgitation through the nose, or hypernasal speech warrants close inspection, digital palpation of the palate, and direct flexible fiber-optic nasopharyngoscope examination of the nasopharynx before a pediatric patient undergoes an adenoidectomy. Lateral pharyngeal (ie, neck) x-rays show obliteration of the nasopharyngeal air column and may be helpful in evaluating the sizc of the adenoids relative to the size of the nasopharyngeal airway. The relationship of thc adenoids to the posterior choana, the e u s t a c h i a n tubes, and the d i n i c n s i o n s of t h e nasopharynx i n the frontal plane, however. are not ussesscd well by this method. The indications for adenoidectomy (ie, infection, upper airway obstructions) are listed in Table 2. Figurcs 2 iind 3 show tonsillar and adenoid hyperplasia, respectively, that are indicative of the need for surgical removal.

INDICATIONS FOR ADENOIDECTOMY'

Infection Recurrent acute nasopharyngitis or adenoiditis despite appropriate medical treatment Chronic or recurrent acute sinusitis despite appropriate medical treatment Chronic otitis media with effusion despite appropriate medical treatment Recurrent acute or chronic otitis media despite placement of tympanostomy tubes in child Resistant otorrhea with tympanostomy tubes in place UuDer ainvav obstruction not associated with other causes Sleep apnea and/or severe sleep disturbance Cor pulmonole not attributable solely to other causes Complete nasal obstruction with malocclusion, recurrent nasopharyngitis, and/or sinusitis Failure to thrive not attributable solely to other causes Obligate mouth breathing not attributable to other causes Speech abnormalities not attributable to other causes

Upper airway obstruction associated with other causes Congenital craniofacial abnormalities resulting in longface syndrome Dental growth abnormalities Cardiac disease exacerbated by upper airway obstruction Other

PREOPERATIVE CONSIDERATIONS

* Suspected adenoid tissue malignancy

Otorhinolaryiigologists must consider the potential benefits and possible complications before recommending T&A procedures to parents of pediatric patients. When surgeons obtain informed surgical consents from the parents o f pediatric patients, they discuss the potential risks of T&A procedures, which include the possibility of intraoperative and postope r a t i v c hemorrhage , post o p e r a t i v e h y p e rn a s a 1 speech, airway obstruction, or nasopharyngeal stenosis. Death after T&A procedures is rarc, hut the risk is approximately 1 in 16,000 surgical procedures.'" Stundurd laboratory tests. Preoperative hemoglobin (Hgb) and hernatocrit (HCT) blood levels should be obtained on pediatric patients undergoing T&A procedures. Tonsillectomy and adenoidectomy procctlures should not be performed on pediatric patients w h o have Hgh counts of less than 10 g/dL or HCT levels of less than 30%;of the total blood volume with-

* Adapted from the guidelines of the American Academy of Otolaryngology-Head and Neck Surgery, Pediatric Otoloryngology Subcommittee. out an explanation of these laboratory test results. In addition, a sickle cell anemia screening test should be obtained on all African-American patients who have not had this test performed previously. Coagulopathy screening. In this era of cost consciousness, evaluation of the efficacy of traditional coagulopathy screening tests is warranted. Only 2%) to 4% of all patients undergoing T&A procedures have coagulopathy disorders that may result in hemorrhagic complications during surgery."' Pi-eoperative coagulopathy screening tests (eg. prothrombin time [PT], partial thromboplastin time I PTTI) should be perfornied only on those patients 890

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infections in pediatric patients. Pentonsillar abscess. Patients with peritonsillar abscesses are exceptions to this rule. These patients must be taken to surgery for incision and drainage (I&D) of the peritonsillar abscesses because of the potential seriousness of their disease. Such patients typically will undergo I&Ds and then have tonsillectomies six weeks later, or they may have “hot” (ie, quinsy) tonsillectomies. Immunity considerations. The effect of the removal of tonsils and adenoids on the competence of patients’ immune systems also should be considered. Most studies have shown no adverse effects on patients’ health after T&A procedures, and there is no evidence of increased malignancy.24In fact, accelerated height and weight gains have been documented in many children six months after T&A procedures.’s

with known or suspected coagulation disorders. Patients with familial or personal histories of bleeding problems (eg, abnormal bleeding or bruising tendencies during dental extractions or other surgical procedures, heavy menstrual periods) should be screened by laboratory coagulopathy tests. If these laboratory test results are abnorrnal or the clinical history is highly suspicious, a full hematologic workup is indicated.?’ Researchers have studied the efficacy of preoperative PT and PTT screening tests on patients with no history or clinical signs indicating possible bleeding disorders.?’ Although preoperative PT and PTT laboratory test results occasionally identify patients with occult von Willebrand’s disease or coagulopathy disorders, the prevalence of bleeding disorders in patients with negative histories and normal physical examinations is extraordinarily low.23As a result, PT and PTT laboratory tests have little predictive value for surgical bleeding tendencies and should, therefore, be reserved for patients with known or suspected coagulopathies. Respiratory problems. Patients with poorly controlled asthma or who are wheezing actively require preoperative management by a pediatric pulmonologist before undergoing T&A procedures. These children are monitored with extreme care postoperatively. Children with acute infections (eg, tonsillitis, adenoiditis, upper respiratory infections) can have increased intraoperative bleeding, and their infections may spread to their lower respiratory tracts. It is desirable to delay T&A procedures for two or three weeks to permit resolution of acute

Children who undergo T&A procedures should be prepared for their experiences well in advance of scheduled surgeries. Perioperative nurses can avoid negative psychological consequences in previously well-adjusted children by careful planning. For children who are emotionally disturbed, specialized professional advice may be appropriate to help minimize children’s misinterpretations of surgical events. Parents and perioperative nurses should explain the expected course of surgical events to children undergoing T&A procedures cornmcnsurate with children’s developmental stages and abilities to comprehend. Children should be informed in advance that they will experience a certain amount

Figure 2 Tonsillar hyperplasia as seen by the surgical team members during a tonsillectomy procedure. The pediatric patient is supine on the OR bed.

Figure 3 Adenoid hyperplasia as seen by the surgical team members during an adenoidectomy procedure. The pediatric patient is supine on the OR bed.

PREOPERATIVE PATIENT PREPARATION

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of postoperative discomfort but that every effort will be made to minimize their discomfort after surgery. Coloring books, storybooks, and videotapes can be helpful in preparing children for T&A procedures. In our hospital, child life specialists are available to help prepare anxious children and their parents for perioperative experiences. Nurses should encourage families to participate in preoperative anesthesia visit programs. During these visits, families tour the facilities and meet anesthesia care providers and perioperative nursing staff members. Nurses conducting preoperative tours should give children opportunities to handle and wear anesthesia face masks and see the anesthesia equipment that will be used to induce general anesthesia. Nurses conducting preoperative tours provide parents with diet and activity instruction sheets before T&A procedures so that parents are prepared for the care of their children before and after surgery. Children generally can have solid food until eight hours before surgery, clear liquids until four hours before surgery, and then be NPO until after surgery. Preoperative nurses reinforce surgeons’ instructions to discontinue children’s aspirin use at least one week before surgery because aspirin affects platelet adhesion and increases the incidence of intraoperative and postoperative bleeding. Nurses also instruct parents to obtain homework assignments from their children’s teachers for up to two weeks after surgery so that recovering children can avoid educational delays. If children undergoing T&A procedures are participating in team athletics, their coaches and teammates need to be prepared for the children’s two-week absences from these events after surgery.

every effort to reassure the family members and answer the child’s and parents’ questions. The nurse instructs the parents that one or both parents should be at the child’s bedside shortly after the child awakens in the postanesthesia care unit (PACU), emphasizing that parental presence is essential for comforting a child after surgery and for reassuring a child who experiences emergence “nightmares.” Circulating nurse duties. The circulating nurse ensures that the OR is properly set up with the necessary instruments and equipment to perform a T&A procedure. He or she checks to see if the surgeon’s headlight and hydraulic chair, electrosurgical unit (ESU), and suction equipment are working properly. We use a large tool cabinet to carry all the basic and frequently used otorhinolaryngology specialty supplies, and this cabinet is brought into the OR or placed outside the room. After the circulating nurse prepares the OR, he or she checks the patient’s medical chart for the appropriate laboratory test results, a signed surgical consent form, and the history and physical examination notes. If the child has participated in a preoperative tour, the nurse reviews the child’s reactions to the experience. Additionally, the circulating nurse looks at the surgery preoperative assessment forms for information regarding the child’s preferences, coping behaviors, nicknames, and other pertinent personal information. The circulating nurse meets the child and parents in the preoperative holding area. The circulating nurse attempts to establish rapport with the family members and to determine how the child will separate from his or her parents. The nurse checks the child’s ID bracelet and asks the parents to verify the child’s name, age, time of last food and liquid intake, DAY OF SURGERY and any known allergies. The circulating nurse After the child and his or her parents arrive in allows the child to bring a favorite toy, doll, blanket the preoperative holding area, the preoperative nurse or other security item into the OR and allows the interviews the child and parents. The nurse elicits a child to choose his or her mode of transportation to complete health history, including current medica- the OR. A tricycle, wagon, scooter, toy car, or helitions, known allergies, and a past history of malig- copter are some of the transportation options at our nant hyperthermia (MH) or bleeding tendencies. The facility. In addition, the child may choose to walk or preoperative nurse places an identification (ID) to be carried by his or her parent. bracelet on the child, records baseline vital signs, Patient considerations. The circulating nurse and reviews the child’s medical chart for a signed offers the child explanations that are appropriate to surgical consent form and laboratory test results. his or her age and developmental level. For example, The preoperative nurse emphasizes that one or a five-year-old child usually will display fear and both parents should remain with the child during the curiosity and thus may be calmed by explanations of preoperative waiting period and immediately before how machines work. This child typically enjoys and the child is transferred to the OR. He or she makes is distracted by applying his own ECG pads and n92 AORN JOUKNAL

watching his or her ECG pattern on the television monitor. T h e child may want to hold his or her own face mask during general anesthesia induction and may be comforted by being told. “This medicine you are smelling makes you feel funny and that is exactly what is supposed to happen.” Adolescents may appear quite bored and nonchalant. Ado- Figure 4 Mayo stand with surgical instruments for tonsillectomy and adelescents frequently imagine that noidectomy procedures (top row, from left) one suction tubing, two tonsilparades of people will be walking grasping clamps with attached tonsil sponges, one self-retaining mouth through the OR, gazing at them gag, one tenaculum. one Hurd dissector and pillar retractor, one smooth while they are anesthetized. They forcep, five adenoid curettes, assorted sizes; (boftom row, from /en) gauze may be reassured by being told sponges, electrosurgical handpiece cord, two long hemostat clamps, two how many people will be i n the 1 0-Fr red rubber catheters, one plastic suction tip. OR during surgery. Pulling the shades d o w n o n the OR outer door after entering the OR can provide comfort to as easy and safe as possible. One of the primary preadolescent patients without saying a word. After operative goals of the circulating nurse and the anesmonitors are applied, the circulating nurse can thesia care provider is to avoid frightening the child. relieve adolescents’ anxiety by reassuring them that Even very young children can be quite cooperative if they feel some measure of control. they will be covered during surgery. Different methods must be employed according Anesthesia considerations. General anesthesia is employed to perform all T&A procedures on children to the level and developmental age of the patient. For and adolescents. A variety of anesthetics are available example, a grade school-aged child who cries may that allow anesthesia care providers to inanage chil- be comforted and may be more cooperative when dren in lighter planes of general anesthesia that allow told, “Even though you are scared, you are still shorter recovery periods. The occasional uncoopera- doing a good job.” tive patient may require preoperative sedation. The anesthesia care provider usually inserts a INTRAOPERATIVE PATIENT CARE peripheral IV line after administering general anesOne parent is allowed in the OR with the child thesia by mask induction. I n some circumstances at the beginning of general anesthesia induction if (eg, a child at risk for MH, ii child who is very the anesthesia care provider believes the parent’s frightened of the anesthesia mask), thc anesthesia presence will help allay the child’s fears. An O R care provider may insert an 1V line before induction assistant escorts the parcnt to the surgery waiting of general anesthesia. In these situations, the preop- area when the child appears to be asleep. Induction and intubation. Regardless of the erative nurse applies a prescribed mixture of local anesthetics (ie, 2.5% lidocaine and 2.5% prilocaine method of induction, the circulating nurse remains at in an emulsion base) to the child’s hands and fore- the head of the OR bed, attentive to the needs and arms one hour before the estimated start of the surgi- direction of the anesthesia care provider until the cal procedure to facilitate a painless venipuncture. child is intubated and the endotracheal (ET) tube is The anesthesia care provider inserts the IV line and positioned properly and secured. After mask inducsecurely tapes the IV line to a padded arm board of tion with halothane and oxygen, the anesthesia care appropriate size to prevent the IV catheter from provider inserts a peripheral IV line and intubates the child with an appropriate-sized oral E T tube. The becoming dislodged. The child’s age, weight, and developmental circulating nurse applies ECG pads, a pulse oximeter level determine whether mask o r IV induction is probe, and a blood pressure cuff of appropriate size. employed. The circulating nurse nnd the anesthesia Surgical setup. lnstrumentation for a T & A procare provider work closely to ensure that induction is cedure usually is part of a standard T&A tray. The 894 AOKN J O U R N A L

Figure 5 The surgeon sits at the child‘s head, with the OR bed in a slight Trendelenburg’s position.

scrub person sets up the majority of the instruments for a T&A procedure on the Mayo stand (Figure 4), and the surgeon connects the self-retaining mouth g i g to the stand. It is extremely important that the scrub person not rest his or her hands or arms on the Mayo stand. The scrub person also must ensure that other team members do not inadvertently lean on the Mayo stand. It is essential that the scrub person maintain the surgical setup completely intact until the patient is out of the OR. If any bleeding occurs during extubation or emergence from anesthesia, the surgery team members must be ready to respond immediately. Positioning and draping. After intubation, the anesthesia care provider and the circulating nurse turn the OR bed 90 degrees to allow the surgeon to have access to the child’s throat. The circulating nurse places a shoulder roll under the child’s shoulders to hyperextend the neck and prevent the aspiration of blood. He or she ensures that ;t safety belt is secured above the child’s knees and that an ESU dispersive pad is properly placed. The scrub person and the circulating nurse perform initial sponge and needle counts. The surgeon applies a sterile head drape and secures it with a nonperforating towel clamp. The scrub person drapes the child’s body with a sterile half sheet. He or she secures the sterile ESU cord and suction tubing and passes them off the surgical field to the circulating nurse, who attaches them to the appropriate units. The circulating nurse records

blood loss during surgery according to hospital policy and procedure. The surgeon sits at the patient’s head, with the OR bed in a slight Trendelenburg’s position (Figure S ) . He or she retracts the child’s mouth open with a self-retaining mouth gag and depresses the child’s tongue with an appropriate-sized blade retractor. The surgeon suspends the self-retaining mouth gag and attached blade from the Mayo stand (Figure 6). T h e s u r g e o n p a s s e s t w o 10-Fr red rubber catheters (ie, one catheter into each nostril) down the child’s nasopharynx, grasps the catheters with a smooth forcep, and pulls them out through the

Figure 6 The self-retaining mouth gag and attached blade is suspended from the Mayo stand.

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terize bleeding wound edges o r tissues.

Tonsillectomy procedure. There are a number of successful and time-honored techniques for t h e removal of tonsils. T h o s e most commonly used include the electrosurgical technique, dissection and snare method, guillotine technique, and laser method. The electrosurgical technique is favored by our surgeons because it results in rapid hemostasis, less surgical time, and decreased postoperative discomfort. The surgeon uses new elecFigure 7 The ends of two 10 Fr red rubber catheters that retract the trocautery blade tips to move child’s soft ualate are secured with curved mosauito clamps and placed on . each tonsil. T h e s c r u b person gauze pads’to avoid injury to the child‘s face. holds a plastic tonsil suction tip in t h e c h i l d ’ s m o u t h t o c l e a r child’s mouth. He or she secures the two ends of the plume from the electrosurgical handpiece and blood catheters together with curved mosquito clamps and from the surgical site that could obscure the surretracts the child’s soft palate. T h e scrub person geon’s vision. The surgeon usually removes the places the curved mosquito clamps on two folded 4 x right tonsil first, and the scrub person tags the right 4 gauze pads to avoid injury to the child’s face (Fig- tonsil with a silk suture to facilitate identification by ure 7). One of the red rubber catheters may be posi- the pathologist. After the circulating nurse ensures that the electioned with its tip in the child’s oropharynx and the other end connected to suction tubing for evacuating trical grounding is correct and the ESU is set on 25 W, the surgeon grasps the right tonsil with a smoke from the electrosurgical handpiece. Adenoidectomy procedure. T h e s u r g e o n tenaculum and retracts it medially. He or she makes inspects the adenoids with a magnifying dental mir- a cautery incision in the mucosa, separating the tonror. If the adenoid tissue is obstructive or if the child sil from the anterior muscular pillar. The surgeon has had symptoms of recurrent adenoiditis or recur- takes care to stay near the capsule of the tonsil so rent otitis media, the surgeon uses an appropriate- that a plane is created between the capsule and the sized adenoid curette to remove the adenoids. The tonsillar bed. Typically, this is a bloodless plane that surgeon pushes the cutting edge of the adenoid allows rapid dissection. The surgeon dissects the curette down the septum along the vault of the superior pole first and carries the dissection inferiornasopharynx and over the odontoid process of the ly, taking care to preserve the anterior and posterior axis. He or she takes care not to injure the submu- muscular pillars and avoiding injury to the base of cosal fascia or the superior pharyngeal constrictor the tongue muscles. If any significant oozing is present, the surgeon muscle. The surgeon uses a small curette or adenoid p a c k s t h e right tonsillar bed with r a d i o p a q u e punch to clean additional adenoid tissue out of the sponges. H e or she performs a similar procedure on posterior choanae, if adenoid tissue is present. He or the opposite tonsil. The surgeon and the scrub person she packs sterile radiopaque sponges in the child’s take extreme care to prevent contact between the nasopharynx for at least five minutes for initial electrosurgical handpiece and the ET tube or plastic hemostasis. The surgeon then uses an electrosurgi- tonsil suction tip, as this could result in an airway cal handpiece with attached suction tubing to cau- fire. Surgical team members also take precautions to

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Figure 8 The electrosurgical handpiece is secured when it is not in use to prevent contact with the endotracheal tube, the plastic suction tip, or metal objects to prevent airway fires or burns to the child.

avoid contact between the electrosurgical handpiece and any metal objects that could conduct electrical current and cause a bum on the child’s lips or oral conmiissure (Figure 8). After approximately five to 10 minutes, the surgeon removes any remaining packs from the adenoid and tonsillar beds and uses a magnifying dental mirror to inspect for bleeding. If bleeding is present, he or she uses the electrosurgical handpiece with suction attached to cauterize the bleeding tissue. The surgeon then places a figure-of-eight silk suture around the bleeding tissue by incorporating the rnuscle around the bleeding vessel site. W o u n d closure. T h e surgeon irrigates the child’s nasopharynx with normal saline instilled through the nostrils with a large bulb syringe and suctions blood clots and fluid through the mouth to prevent aspiration. He or she then passes a small suction catheter into the child’s stomach to evacuate any swallowed blood or residual stomach contents. After emptying the child’s stotnach, the surgeon gives the suction catheter to the anesthesia care provider. The s u r g e o n r e m o v e s t h e mouth g a g , red r u b b e r catheters, sponges, and head drape after he or she is satisfied that hemostasis has been obtaincd. The circulating nurse labels and sends all specimens for gross pathology examination. Twenty minutes before the child is tlansferred to the PACU, the circulating nurse gives a telephone report to the PACU nurse assigned to reccivc the child. The scrub person and the circulating nurse perform a final count of needles and sponges. The circulating nurse places a clean towel at the head of the stretcher to capture secretions and ensures humidified oxygen is in place on the transfer stretcher.

T h e anesthesia care provider extubates the supine child on the OR bed. Surgical team members place the child on his or her side in a semirecumbent position on the transfer stretcher to prevent possible aspiration. The anesthesia care provider positions thc humidified oxygen mist near the child’s mouth. The circulating nurse covers the child with a warn1 blanket, applies a safety strap, and raises the side rails of the stretcher before transporting the child to the PACU. The circulating nurse, the surgeon, and the anesthesia care provider transport the child to the PACU. Prescribed medications. At our institution, all children undergoing T & A procedures are treated with intraoperative antibiotics. Our surgeons prefer to use IV ampicillin (ie, 100 m g k g ) followed by a seven-day course of oral amoxicillin (ie, 20 to 40 m g k g every eight hours) to minimize the possibility of infection that can exacerbate other troublesome postoperative symptoms (eg, pain, lassitude, poor oral intake) after T&A procedures.26 Our surgeons also believe the administration of systemic steroids (ie, 0.4 mg/kg of dexamethasone) in the OR may be beneficial in reducing postoperative discomfort and in improving immediate postoperative oral intake in children who have undergone T&A procedure^.?^ Additional studies regarding the safety and efficacy of steroids are ongoing. Finally, our surgeons recommend the intraoperative administration of ondansetron (ie, Z o f r a n ) f o r control of nausea in children undergoing T & A procedures.?x POSTOPERATIVE PATIENT CARE

The PACU nurse obtains a baseline set of the child’s vital signs, including temperature, blood pressure, heart rate, and respirations. The anesthesia care provider gives the PACU nurse a detailed report of the anesthetic agents used, 1V tluids and intraoperative medications given, estimated blood loss, and other pert inent medical history. The circulating nurse adds any details regarding the child’s psychosocial needs, family situation, and his or her preoperative behavior. After the child is sufficiently awake, the nurse calls the parents into the PACU. The child may sit in a parent’s lap or lie on the PACU strctchcr with the head of the stretcher elevated. The PACU nurse encourages the child to sip clear fluids and administers pain medications as ncccssary. The child usually is quite anxious and needs constant comfort. 900

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If the child vomits bloody material, the child and parents usually become quite frightened. The PACU nurse reassures the child and the parents that this is not a serious incident and administers prescribed antiemetics to the child. Nausea and vomiting usually are controlled with promethazine (eg, Phenergran), which can be administered intramuscularly or by rectal suppository. Alternatively, ondansetron (ie, Zofran) may be useful in the postoperative period.2y The PACU nurse observes the child for signs of fever; respiratory distress; pain: lethargy; and most importantly, bleeding. Initial I V fluid replacement is required because the child has been NPO for some time. If the child is cooperative, the PACU nurse can use a flashlight to check the back of t h e child’s throat periodically for excessive bleeding. He or she avoids vigorous suctioning to prevent inadvertent postoperative hemorrhage. Pain management. Pain typically is managed with 0.5 mg/kg of acetominophen 300 mg and codeine 30 mg (ie, Tylenol with codeine #3). An ice collar may provide some temporary pain relief. Prescribed mild sedatives may be administered, as needed. Fluid replacement. The PACU nurse encourages oral fluids as soon as the child is alert. This initially consists of cold clear liquids and noncitrus fruit juices, as well as ice pops or crushed ice. The typical posttonsillectomy diet consists of water, soda, ice cream, ice pops, gelatin, pudding, mashed potatoes, and scrambled eggs. If the child is admitted to the hospital, he or she should have a minimum oral intake of 240 mL in the first six hours after surgery and 1,000 mL in the first 24 hours after surgery before being discharged. Inpatient versus outpatient recoveries. There is great controversy in today’s cost-conscious Iicalth care environment regarding the merits uf inpatient versus outpatient T&A procedures. Adenoidectomy procedures hy themselves do not cause sufficient pain, sore throat, or postoperative bleeding to require overnight hospital stays for the majority of pediatric patients. After these children are assessed by their anesthesia care providers and surgeons, they can be discharged safely three to six hours after surgery if PACU nurses have observed no

bleeding, lethargy, or problems with fluid intake. Pediatric patients who have undergone tonsillectomy procedures, on the other hand, have greater postoperative pain, require more pain medications, are more lethargic, and take less oral fluids after surgery. Overnight hospital stays allow postoperative nurses to hydrate children with IV fluids, observe children for signs of bleeding, improve pain and nausea management, and reinforce discharge instructions. The distance between children’s homes and hospitals is another important factor that may necessitate overnight hospital stays for children undergoing tonsillectomy procedures. Postoperative pediatric patients are far more comfortable and alert when they are discharged the morning after surgery. Some insurance companies may refuse to pay for overnight hospital stays unless complications develop. These situations may be dealt with by surgeons on case-by-case bases. DISCHARGE INSTRUCTIONS

Postoperative nurses provide oral and written instructions to parents on the early signs of dehydration (eg, dry mouth, sunken eyes, no tears when crying, decreased urine output). They ask parents to be particularly wary of any postoperative bleeding. Parents are instructed to bring their children to emergency departments closest to their homes at the first signs of postoperative hemorrhage. Nurses instruct the parents that the presence of bright red blood in the child’s oral cavity confirms the diagnosis of postoperative hemorrhage. Occasionally, the child will swallow blood for a period of time before parents become aware of postoperative hemorrhage. The child typically will have hematemesis or coffee-ground material present in vomited liquid. Nurses instruct the parents to contact the surgeon or his or her office nurse for further instructions if their child is having difficulty with oral intake or excessive pain during the immediate postoperative period. Parents are advised that the child’s preoperative hyponasal, muffled voice and speech may change following the T&A procedure. Undesirable postoperative qualities such as a higher-pitched voice or hypernasality typically subside within six weeks after surgery. Nurses also tell parents to expect their children to have complaints of ear pain, which results from 901

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rcferrctl pain from the throat, and to anticipate children's bad breath. which is caused by debris and bacteria covering the healing tonsillar fossa. In addition. ;I Iemporary postoperative weight loss often is encountered. Parents are instructed to return with their child 14 days after surgery for their first postoperative visit to the surgeon. Before the first postoperative visit, parents often notice that their child has an increased sense of smell and that his or her problenrs with snoring and nocturnal enuresis have resolved. POSSIBLE COMPLICATIONS

Researchers report a 14% incidence of complirelated to T&A procedures, all of which are rratlily managed or self-limiting."' The age-ad,justed tlcath late from general anesthesia has been estimatc(I ;I( orie in 14,000 to 16,000 T&A procedures." Additional general anesthesia risks associated with T&A procedures include traumatic intubations, cardiac arrhythmias, and MI 1 episodes. I n extreme upper airway obstructions, children can develop pulmonary edema or congestive heart fiilure after acute reversals of chronic obstructions. C'hildren with this extreme proclivity should be monitored in intensive c a r e units and may require overnight intubations with ventilator support and d i urctic therapy. 1 lemorrhage is the most common postoperative complication of T&A procedures. and it occurs in approximately 1 % to 4 % ~of patients undergoing these procedures.i' Occasionally, hemorrhage may result when occult bleeding disorders are present; however, bleeding most commonly is associated with the early sloughiny of the eschar covering tonsillar blood vessels. We believe that children who arc dehydrated are more prone to this complication. and we stress to parents the need to adequately hydrate their children during the early postoperative period. Prevention of her~iorrhagedepends primarily on sound surgical technique and on reduced activity in the immediate postoperative period. Delayed bleeding can occur when the escliiircomes off at fivc to I0 days after surgery. If ignored o r unrecognized, considerable blood loss can be encountered before the child is brought inlo the physician's office tir hospital for attention. The incidence of velopharyngeal insufficiency after T&A procedures has been estimated iit one i r i I ,SO0.?4 Postoperative transient hypernasality may cations

Q

occur secondary to pain. The child may he Iioldiny the throat muscles at rest during speech and s\inllo\ving and not closing his or her nasopharynx. Thi\ c;in become habit forming x i d persist long after the pain is resolved. in which case speech therapy is indicated. The incidence o f nasophitryngeal stenosis is estimated at three per 100,000 T&A procedures.'? Predisposing factors include excessive mucosal destruction, surgery performed in the presence of pharyngitis, revision of adcnoid surgery with removal of pharyngeal bands. keloid fbmiation, and sacrifice of the posterior tonsillar pillars. Trcatment of this c o n d tion is quite difficul~;mcl m a y r c y i r e the placement of skin grafts or local niucosal t l i i p ~ . ' ~ SUMMARY

Tonsillectomy and adenoitlectomy procedures constitute it large percentage 0 1 busy pediatric otolaryngology practices. These pi-ocecltircs remain the most frequently performed major sui-gical procedure in childhood, and, therefore. :ire pi-ocedures with which every perioperative nurse should be familiar. A multidisciplinary team ;ipproiicli to 'I&A procedures reduces the fear, morhidity. discomfort, and costs associated with surgci-y ;uid rrraxirnizes optimal surgical outcomes in pediatric paticnts. A

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Craig S., erkay, m d, CACS. FAAP, is an associate progfessor in otoloyngology and pediatircs ast Esatern Virgina Medical School and idrector of pediatric otologyn gology at Childre's Hospital of the King's daughers. Norflolk, Va.

Dvaid H. Drrow, MD, DDs, is a ana asistant professor inm otolarygonlogu amd [rdoatrocs at Esternm vir ginia Mecial Schol, NOrfolmk ,va

Susan M.d L:efebrvre, Rn, CNOer, is and otohinplayrngolgyt staff nurse at children's hospital of teh king s Daughers, Norfolk,. va.

Layrngology 103 (February 1994) NOTES 1, C S Derkay, “Pediatric oto135-138. 13. Schulman et al, “Streptococcal laryngology procedures in the United pharyngitis: The case for penicillin States: 1977-1987,”Internatioriul Jouixal of Pediatric Oto~~hinoluryi- therapy,” 1-7. 14. R E Behrman et al, N e h n g(i10gy 25 (January 1993) 1-12. 2. D B Keams, S M Pransky, A B Textbook cfPediutrics, 14th ed (W B Seid, “Current concepts in pediatric Saunders Co, 1992) I06 1- 1062. 15. C D Bluestone, J 0 Klein, adenotonsillar disease,” Em.. Nose “Otitis media, atelectasis, and niid Tlir-outJourriuI 70 no 1 (1 990) eustachian tube dysfunction,” in 15-19. Pediatric Otolaryngology, ed C D 3. J L Paradise, “Tonsillectomy Bluestone, S E Stool (Philadelphia: and adenoidectomy,” in Pediatric, W B Saunders Co, 1990) 408-486. Otolaryriplogy, ed C Bluestone, S E 16. J L Paradise et al, “Efficacy of Stool (Philadelphia: W B Saunders adenoidectomy for recurrent otitis CO, 1990) 915-926. media in children previously treated 4. G L Adams, L R Boies, Jr, P A with tympanostomy tube placement: Hilger, Boies Fundun7entals rf OtoResults of parallel randomized and l u / ~ ~ r i ~ ~ o lAo Te.rthook ~qy: of’ Eur-, non-randomized trials,” Joiiixul of No.sc, arid Thruiut Diseuses. sixth ed the Americuii MedicuI Associutiori (Philadelphia: W B Saunders Co, 263 (April 1990) 2066-2073. 1989) 350-357. 17. D Paul, ‘‘Sinus infection and 5 . J L Paradise et al, “Efficacy of adenotonsillar disease in pediatric tonsillectomy for recurrent throat patients,” LarynRoscop 91 (June infections in severely affected chil1981) 997-1001. dren,” The N e w England Jour-nu/ of 18. Ihid. Merlir.ir7e 310 (March 1984) 67419. Zalzal, Cotton, “Adenotonsil683: Derkay, “Pediatric otolaryngollar disease,” 1 189- I2 I I . ogy procedures in the United States: 20. S C Manning et al, “An assess1977-1987,” 1-12. 6. Derkay, “Pediatric otolaryngol- ment of preoperative coagulation screening for tonsillectomy and adeogy procedures in the United States: noidectorny,” Irrternutinrial . / o i m d 1977-1987.’’I - 12. 7. G H Zalzal. R T Cotton, “Ade- of Pcdintric. Otola r-yrtp)lo,yy I 3 notonsillar disease,” in Otolar;yri,~olo- (October 1987) 237-244. 2 I . C S Derkay, E Werner, E Plotcy-y--Hrudarid N e d Sur-geq,ed C W Cummings et al (St Louis: The C V nick, “Management of children with von Willehrand’s disease undergoing Mosby CO, 1986) 1189-1211. adenotonsillectomy,”Amer.ican Jour8.Ihid. 9. S T Schulman el al, “Streptoriul of Orolur-yngology (in press). 22. Manning et al, “An assessment coccal pharyngitis: The case for penicillin therapy,” Pediatric, Ii?fectioLis of preoperative coagulation screening Discuses .lourwd 13 (January 1994) for tonsillectomy and adenoidectol11y,” 237-244. 1-7. 23. Derkay. Werner, Plotnick, 10. Ihill. “Management of children with von I 1. Zalzal, Cotton, “AdenotonsilWillebrand’s disease undergoing lrtr disease,” 1 189- I2 I 1. adenotonsillectomy.” 12. D Huminer et al, “Mycoplasma and chlamydia in adenoids and 2 4 . 0 Ruuskanen, T Vanha-Pettonsils of children undergoing adetula, K Kouralamin, “Tonsillectomy, appendicectomy and Hodgkin’s disnoidectomy or tonsillectomy,” ease,”Lancet 1 (May 1971) 1127Ar7rral.s of Otology . Rhinolo
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1128; C Cassimos et al, “The frequency of tonsillectomy and appendectomy in cancer patients,” Cancer 32 (December 1973) 1374-1379. 25. E F Williams et al, “The effects of adenotonsillectomy on growth in young children,” Otolar-y/z~yolog.y4feudarid Neck Surgery I04 (April 1991) 509-516. 26. S Telian et al, “The effect of antibiotic therapy on recovery after tonsillectomy in children: A controlled study,” Archives of Ofoluryrrgolog.y4fead nnd Neck Surgery 1 12 (June 1986) 610-615. 27. F I Catlin, W J Grimes, “The effect of steroid therapy on recovery from tonsillectomy in children,” Ai.chiws ef Otolaiyngolog.y-Heud und Neck Suyyer-y 117 (June 1991) 649-652; M S Volk et al, “The effects of preoperative steroids on tonsillectomy patients,” Otoluryngolog.y-Sicad and Neck Surgery 109 (October 1993) 726-730. 28. S R Furst, A Rodarte, “Prophylactic antiemetic treatment with ondansetron in children undergoing tonsillectomy,” Aiiesthe.siology 8 I (October 1994) 799.803. 29. /hid. 30. Paradise et al, “Efficacy of tonsillectomy for recurrent throat infection in severely affected children,” 674-683. 3 I . Zalzal, Cotton, “Adenotonsillar disease,” 1189-1211. 32. Ibid. 33. Manning et al, “An assessment of preoperative coagulation screening for tonsillectomy and adenoidectomy,” 237-244. 34. A G Gibb, “Hypernasality (rhinolalia apeita) following tonsil and adenoid removal,” .lourrial of l u r y t i gology and Otology 72 (Fall 1958) 433-440. 35. W B Lehmnn, T H Popek, Jr, W R Hudson, “Nasopharyngeal stenosis,” Luiyigoscope 78 (March 1968) 371-385. 36. Ihid.