Common Mistakes & Exam Pearls
Airway hyper-reactivity → laryngospasm and desaturation. Defer elective surgery ~2–4 weeks after a respiratory infection.
OSA children are exquisitely sensitive to opioid-induced respiratory depression. Titrate, favour multimodal analgesia, and monitor in recovery.
The Boyle–Davis gag kinks or compresses the tube — a rising airway pressure or falling tidal volume is the warning; recheck whenever the gag is opened or the head repositioned.
Blood and secretions pool and soil the airway. Extubate awake in the lateral, head-down "tonsillar" position and suction the nasopharynx for a coroner's clot.
Swallowed blood hides true loss. Resuscitate fully before induction and treat as a full-stomach RSI.
Q: What are the anaesthetic concerns in tonsillectomy?
Paediatric patient, shared airway, OSA (opioid sensitivity), a vascular field with post-tonsillectomy bleeding risk, and PONV.
Q: Classify post-tonsillectomy haemorrhage.
Primary (on table), reactionary (<24 h — slipped ligature / rising BP), secondary (>24 h — infection/sloughing).
Q: Why is blood loss underestimated in a post-tonsillectomy bleed, and how do you induce?
Much blood is swallowed. Treat as hypovolaemic shock with a full stomach — resuscitate, then RSI with cricoid pressure and a smaller ETT.
Q: What is Brodsky grade 4?
Tonsils occupying >75% of the oropharyngeal width ("kissing tonsils").
Q: Which antiemetics and why dexamethasone?
Ondansetron 0.1 mg/kg + dexamethasone 0.1 mg/kg — dexamethasone also reduces oedema and pain in one of the most emetogenic paediatric operations.
Q: Risk of local anaesthetic + adrenaline infiltration into the tonsillar bed?
Excess volume can cause a bilateral glossopharyngeal (IX) nerve block → post-operative airway/respiratory obstruction.
Q: What is a "coroner's clot"?
A concealed nasopharyngeal clot, not visible, that can obstruct the airway after extubation — always suction under vision before waking.
References
- Dr. Tanya Chawla. Anaesthesia for Tonsillectomy — viva notes (primary source for this topic).
- Gropper MA, et al. (eds). Miller's Anesthesia, 9th Edition. Anaesthesia for ENT & the Paediatric Patient. Elsevier; 2020.
- Butterworth JF, Mackey DC, Wasnick JD. Morgan & Mikhail's Clinical Anesthesiology, 7th Edition. Otolaryngologic & Paediatric Anaesthesia. McGraw-Hill; 2022.
- Hines RL, Marschall KE (eds). Stoelting's Anesthesia and Co-Existing Disease, 8th Edition. Elsevier; 2022.