Pre-operative Assessment & Optimisation
History
① Symptoms of adenotonsillitis — dysphagia, sore throat, difficulty swallowing, rhinorrhoea, earache, headache.
② Symptoms of obstruction / OSA — hyponasal speech, snoring, mouth-breathing, witnessed apnoeas, restless sleep, daytime somnolence.
③ Bleeding disorder / anaemia / family history of bleeding.
④ Past history of similar complaints; previous anaesthesia. ⑤ Immunisation & developmental milestones.
② Symptoms of obstruction / OSA — hyponasal speech, snoring, mouth-breathing, witnessed apnoeas, restless sleep, daytime somnolence.
③ Bleeding disorder / anaemia / family history of bleeding.
④ Past history of similar complaints; previous anaesthesia. ⑤ Immunisation & developmental milestones.
🔍 Examination
- General: the adenoid facies — enlarged tonsils, open mouth, crowded teeth, high-arched palate, hitched-up upper lip, mouth-breathing.
- Oral cavity: mouth opening, degree of tonsillar enlargement (Brodsky/Mallampati) — assess airway for difficult ventilation.
- Nasal cavity, enlarged neck nodes, and screen for active RTI / wheeze (defer if present).
- For the paediatric OSA workup, questionnaires such as McGill oximetry and STBUR ("Sleep Trouble Breathing, Unrefreshed, Restless") help predict perioperative respiratory risk.
📊 Brodsky grading of tonsillar size (oropharyngeal occupancy)
- Grade 0 — tonsils within the fossa (tonsillectomy done). Grade 1 — <25%. Grade 2 — 25–50%. Grade 3 — 50–75%. Grade 4 — >75% ("kissing tonsils").
- Higher grades predict a more difficult mask airway and greater obstruction risk.
| Investigation | Why |
|---|---|
| CBC + platelets | Anaemia, occult infection |
| Coagulation profile | Bleeding risk (vascular field) |
| Chest X-ray (if RTI) | Also gauges size of adenoids |
| ECG & 2D echo (if OSA) | Screen for cor pulmonale / pulmonary hypertension from chronic obstruction |
Pre-op preparation: antibiotics + IV fluids as indicated; treat/defer active infection; ensure fasting; group & save if bleeding risk. Sedative premedication is used cautiously in the OSA child.