Ambulatory Anesthesiology

E   NARRATIVE REVIEW ARTICLE

Care of the Pediatric Patient for Ambulatory

Tonsillectomy With or Without Adenoidectomy: The
Society for Ambulatory Anesthesia Position Statement
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Marjorie P. Brennan, MD, MPH,* Audra M. Webber, MD, FASA,† Chhaya V. Patel, MD,‡ Wanda A. Chin, MD,§
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Steven F. Butz, MD, SAMBA-F,∥ and Niraja Rajan, MD, FAAP, SAMBA-F, FASA¶

The landscape of ambulatory surgery is changing, and tonsillectomy with or without adenoid-
ectomy is one of the most common pediatric surgical procedures performed nationally. The
number of children undergoing tonsillectomy on an ambulatory basis continues to increase.
The 2 most common indications for tonsillectomy are recurrent throat infections and obstruc-
tive sleep-disordered breathing. The most frequent early complications after tonsillectomy are
hemorrhage and ventilatory compromise. In areas lacking a dedicated children’s hospital, these
cases are managed by a nonpediatric specialized anesthesiologist and general otolaryngol-
ogy surgeon. In response to requests from our members without pediatric fellowship training
and/or who care for pediatric patients infrequently, the Pediatric Committee of the Society for
Ambulatory Anesthesia (SAMBA) developed a position statement with recommendations for
the safe perioperative care of pediatric patients undergoing tonsillectomy with and without
adenoidectomy in freestanding ambulatory surgical facilities. This statement identifies children
that are more likely to experience complications and to require additional dedicated provider
time that is not conducive to the rapid pace and staffing ratios of many freestanding ambulatory
centers with mixed adult and pediatric practices. The aim is to provide health care professionals
with practical criteria and suggestions based on the best available evidence. When high-quality
evidence is unavailable, we relied on group consensus from pediatric ambulatory specialists in
the SAMBA Pediatric Committee. Consensus recommendations were presented to the Pediatric
Committee of SAMBA. (Anesth Analg 2024;XXX:00–00)

GLOSSARY
AAO/HNS = American Academy of Otolaryngology/Head and Neck Surgery; AAP = American
Academy of Pediatrics; ACS = American College of Surgeons;AHI = apnea-hypopnea index;
AHRQ = Agency for Healthcare Research and Quality;ASA = American Society of Anesthesiologists;
ASC = ambulatory surgery center; BMI = body mass index; CDC = Centers for Disease Control and
Prevention; CEBM = Centre for Evidence-Based Medicine; ETT = endotracheal tube; Fio2 = fraction
of inspired oxygen; NSAIDs = nonsteroidal anti-inflammatory drugs; NSQIP = National Surgical
Quality Improvement Program; OSA = obstructive sleep apnea; PACU = postanesthesia care
unit; PRAE = perioperative respiratory adverse events; PS = physical status; RCT = randomized
controlled trial; SAMBA = Society for Ambulatory Anesthesia; SDB = sleep-disordered breathing;
SGA = supraglottic airway; SOE = strength of evidence; STBUR = snoring, trouble breathing, unre-
freshed; URI = upper respiratory infections

T
onsillectomy with or without adenoidectomy is encompass around 6% to 8% of all surgeries performed
one of the most common pediatric surgeries, with annually in the United States.5 The majority of tonsillec-
well over a quarter million cases performed annu- tomies are performed on an ambulatory basis, cared for
ally1—an incidence similar to that of endoscopic sinus by both general and pediatric anesthesiologists.
surgery and rotator cuff repair.2–4 This number is even The primary indication for tonsillectomy is sleep-
more significant given its context—pediatric surgeries disordered breathing (SDB) and obstructive sleep

From the *Department of Anesthesiology, Pain and Perioperative Medicine, Surgicenter; and ¶Department of Anesthesiology, Penn State Milton S Hershey
The George Washington University School of Medicine, Children’s National Medical Center, Hershey Outpatient Surgery Center, Hershey, Pennsylvania.
Hospital, Washington, DC; †University of Rochester School of Medicine
Accepted for publication June 16, 2023.
and Dentistry, University of Rochester Medical Center, Rochester, New
York; ‡Department of Anesthesiology and Pediatrics, Emory School of Funding: None.
Medicine, Children’s Healthcare of Atlanta, Atlanta, Georgia; §Department of
Anesthesiology and Perioperative Medicine, New York University Grossman The authors declare no conflicts of interest.
School of Medicine, NYU Lagone Health, New York, New York; ∥Department Reprints will not be available from the authors.
of Anesthesiology, Medical College of Wisconsin, Children’s Wisconsin
Address correspondence to Marjorie P. Brennan, MD, MPH, Children's
Copyright © 2024 International Anesthesia Research Society National Medical Center, 111 Michigan Avenue NW, Washington, DC 20010.
DOI: 10.1213/ANE.0000000000006645 Address e-mail to mbrennan@[Link].

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 The Pediatric Patient for Ambulatory Tonsillectomy

apnea (OSA), followed by recurrent infection.1 The

Table 1. Modified CEBM SOE
most frequent early complications after tonsillectomy
Systematic review of randomized trials High SOE
are hemorrhage and ventilatory compromise. Rates of Randomized trials or observational studies with Moderate SOE
post-tonsillectomy hemorrhage range widely in the highly consistent evidence
literature but remain around 3% to 5% for pediatric Nonrandomized or historically controlled studies, Low SOE
patients.6 Ventilatory complications such as hypoxia, including case-control and observational studies

laryngospasm, and bronchospasm are far more com- Abbreviations: CEBM, Centre for Evidence-Based Medicine; SOE, strength
of evidence.
mon, with an incidence of 20% in recent studies.7
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Finally, mortality related to pediatric tonsillectomy is

2 to 7 per 100,000 operations.8–10 The overall complica- PREOPERATIVE CARE
tion rate is 117 per 100,000 operations among children Which Comorbidities and Syndromes Preclude
with complex chronic conditions such as neuromuscu- Tonsillectomy and Adenoidectomy in Children at
lar disease, neurologic disease, hematologic disorders, a Freestanding ASC?
congenital genetic disorders, and respiratory disease.9 The main perioperative complications associated
Recent guidelines regarding preoperative testing with tonsillectomy are bleeding and ventilatory
and procedure type (ambulatory versus inpatient) issues such as hypoxemia, laryngospasm, and bron-
from the American Academy of Otolaryngology/ chospasm.14 Individual ASCs should follow estab-
Head and Neck Surgery (AAO/HNS)11 provide valu- lished exclusion criteria with heightened caution for
able recommendations on perioperative management. pediatric airway surgeries and encourage surgeon
However, clinician adherence to these guidelines is adherence to otorhinolaryngology guidelines.11
inconsistent at best. Children who have known risk factors for perioper-
No national outcomes data on pediatric ambula- ative ventilatory complications should be excluded
tory surgery are available after 2010. The National from having a tonsillectomy at a freestanding ASC
Survey on Ambulatory Surgery was the only national because the surgery itself is associated with venti-
study of ambulatory surgical care in hospital-based latory complications.15 These risk factors include
and freestanding ambulatory centers and was last but are not limited to congenital cardiac anomalies
conducted in 2006. Ambulatory Surgery Center (ASC) beyond a patent foramen ovale, bleeding or clotting
National Surgical Quality Improvement Program disorders, sickle cell disease, craniofacial anomalies,
Pediatric does not collect data on routine tonsillec- Trisomy 21, cerebral palsy, and neuromuscular dis-
tomy cases. The Agency for Healthcare Research and orders.16 In addition, children <3 years old and those
Quality (AHRQ) supported a systematic review of with recent upper respiratory infections (URIs) have
surgical outcomes in tonsillectomy for SDB or recur- an increased likelihood of perioperative ventilatory
rent throat infections in 2020, but this review did not complications.
address anesthesia outcomes.12 SAMBA recommends that children with congeni-
In response to requests from our members, the tal cardiac anomalies, bleeding or clotting disorders,
Society for Ambulatory Anesthesia (SAMBA) devel- sickle cell disease, craniofacial anomalies, Trisomy 21,
oped a position statement with recommendations for cerebral palsy, and neuromuscular disorders should
safe perioperative care of pediatric patients undergo- undergo their procedure in a hospital with overnight
ing tonsillectomy with and without adenoidectomy in admission rather than a freestanding surgery center
freestanding ambulatory surgical facilities. The work- (moderate SOE).
ing group was comprised of the pediatric committee
of SAMBA who are primarily pediatric fellowship- Is There a Body Mass Index Cutoff that Excludes
trained anesthesiologists, practitioners with long- Children From Ambulatory Tonsillectomy and
standing pediatric practice, pediatric ASC directors, all Adenoidectomy at a Freestanding ASC?
with ambulatory expertise. The review process began Body mass index (BMI) percentile is the standard used
with a literature search for articles specific to ambu- by the Centers for Disease Control and Prevention
latory pediatric tonsillectomy, summarized by study (CDC) to define pediatric obesity. BMI >95th per-
design, population characteristics, sample size, and centile is classified as obese, and >99th percentile as
outcomes assessed. The Oxford Centre for Evidence- severe obesity. Obesity and obesity class are now rep-
Based Medicine Levels of Evidence13 were modified resented in the pediatric examples of the expanded
(Table 1) to create a hierarchy of evidence for the clini- American Society of Anesthesiologists (ASA) physi-
cal questions from high, moderate, and low strength cal status (PS) classifications as an acknowledgment
of evidence (SOE). The working group formulated of the risk obesity poses to the pediatric surgical
recommendations, and consensus statements were patient.17 Obesity increases the risk for periopera-
sent to the entire Pediatric Committee of SAMBA and tive complications, particularly ventilatory compli-
finally approved by the SAMBA Board of Directors. cations.18,19 Severe obesity in children undergoing

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 E  NARRATIVE REVIEW ARTICLE  

tonsillectomy is independently associated with an adenotonsillectomy have a polysomnogram before

increased risk of perioperative complications20 such surgery due to costs and limited availability outside
as OSA, ventilatory depression, and overnight air- of academic medical centers. Although the AAO-HNS
way events the night following surgery.21,22 Finally, has published specific guidelines for performing poly-
adenotonsillectomy for SDB or OSA in obese children somnograms before adenotonsillectomy surgery,11
is less effective than in nonobese children.23 The most these are rarely followed.26
recent clinical practice guidelines of the AAO/HNS11 Children with symptoms consistent with OSA
recommend polysomnography in pediatric patients are at increased risk for perioperative complica-
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with obesity before tonsillectomy with or with- tions. Therefore, the challenge is identifying those at
out adenoidectomy. However, these guidelines are risk for SDB/OSA syndrome (OSAS) and evaluating
not consistently followed by surgeons.23 Clinicians the severity based on clinical criteria alone in most
assessing patient suitability for ambulatory surgery children.
must therefore use other criteria to assess risk or to The University of Michigan Snoring, Trouble
establish exclusion criteria, including BMI percen- Breathing, Un-Refreshed (STBUR) scale (Table 2) was
tile. A recent survey of members of the Society for developed in 2013.27 The presence of any 3 STBUR
Pediatric Anesthesia found that slightly more than symptoms increased the likelihood of PRAE by
half of ASCs have BMI percentile criteria for pediat- 3-fold, and 10-fold when all 5 symptoms were pres-
ric patients, and that pediatric-only ASCs were more ent. The survey tracked well with polysomnography,
likely than mixed ASCs to have these criteria. Of and the questionnaire is easily administered. The
those centers that utilize BMI criteria, approximately STBUR scale has been validated several times in dif-
half use a cutoff of >95th percentile, and half utilize ferent studies.28,29
>99th percentile.24 A validated adult questionnaire, STOP-Bang, was
Studies have demonstrated that pediatric sub- modified for pediatric use with more typical pediat-
specialty training reduces rates of perioperative ric risk factors for OSA, but has not been validated
ventilatory complications,25 but most perioperative in children. The presence of snoring (S), tonsillar
ventilatory complications are able to be managed by hypertrophy (T), obstruction (O), daytime tiredness
a skilled provider.18 The majority of studies looking or neuropsychological-behavioral symptoms such as
at perioperative ventilatory complications in obese attention-deficit/hyperactivity disorder or daytime
pediatric patients undergoing tonsillectomy with or irritability (P), BMI percentile for age (B), age at diag-
without adenoidectomy are from academic pediatric nostic screening (A), presence of neuromuscular dis-
institutions staffed by fellowship-trained pediatric order (N), and presence of genetic/congenital disease
surgeons and pediatric anesthesiologists and may (G) all predict the risk of OSA.30
not be generalizable to all ASCs. Institutions with less The McGill oximetry score stratifies the severity of
pediatric experience may benefit from more stringent OSA in children. The score ranges from 1 (normal or
BMI criteria. Additionally, even if the patients meet the inconclusive) to 4 (severely abnormal) according to
criteria to be discharged, the required time and staff the number of clusters and the depth of desaturation
intensity for monitoring obese tonsillectomy patients events seen during overnight oximetry.31 The McGill
in postanesthesia care units (PACU) is increased com- criteria accurately detects OSA of moderate severity,
pared to their nonobese counterparts. but a negative result does not reliably exclude OSA.
There is not overwhelming evidence for a specific This test is not appropriate for patients with syn-
BMI cutoff for tonsillectomy in ambulatory pediatric dromes or neuromuscular disorders because desatu-
patients. However, obese and severely obese children rations in these situations can be secondary to central
do have higher risks of perioperative respiratory events.32,33
adverse events (PRAE). Until more data are available,
we recommend the use of age-specific BMI cutoff at
the 95th percentile in freestanding ASCs. Table 2. The STBUR Questionnaire
SAMBA recommends a BMI cutoff of the 95th per- Does your child
centile for adenotonsillectomy at freestanding ASCs 1. snore more than half of the time
2. snore loudly?
(low SOE). 3. have any trouble breathing or struggle to breathe?
4. stop breathing during the night?
How Are Children With SDB Identified? 5. feel unrefreshed in the morning after a night of sleep?
PRAE remain a significant cause of morbidity and When 3 of the 5 symptoms are present the child is 3 times more
susceptible to PRAEs.
mortality during tonsillectomy.9 There are several
When all 5 symptoms are present, the child is 10 times more
ways to evaluate children for the presence of OSA. susceptible to PRAEs.
Polysomnography is a test to assess OSA severity. Abbreviations: PRAE, perioperative respiratory adverse event; STBUR,
However, fewer than 10% of patients scheduled for snoring, trouble breathing, unrefreshed.

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 The Pediatric Patient for Ambulatory Tonsillectomy

Parental report of symptoms has a poor positive controversial. The guidelines from the AAO-HNS
predictive value to identify the severity of OSA.34,35 recommend polysomnography only if there is discor-
The Pediatric Sleep Questionnaire can be unreliable dance between tonsil size and the reported severity
for most patients.36 of SDB symptoms.11,47 In contrast, guidelines from
Any child scheduled for a tonsillectomy with or the American Academy of Pediatrics (AAP) and the
without adenoidectomy for OSA, but without poly- American Academy of Sleep Medicine recommend
somnography, should be assumed to have some that all children undergoing adenotonsillectomy for
degree of OSA. SDB have polysomnography. However, the AAP rec-
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SAMBA recommends that clinicians maintain a ognizes this service may not be readily available and
high degree of suspicion for OSA in patients hav- that alternative testing or referral to a specialist may
ing tonsillectomies and consider incorporating the be warranted.37
STBUR questions in the preoperative screening pro- Preoperative polysomnography has not always
cess (low SOE). demonstrated validity to predict adverse periop-
erative outcomes48,49 due to the disparity between
What Polysomnographic Parameters Exclude a polysomnography measures and the severity of
Child From Ambulatory Surgery in a Freestanding clinical symptoms. Symptoms of SDB have been
ASC? associated with cognitive and behavioral abnor-
Polysomnography, when available, is useful for malities, even in the absence of documented OSA
selecting the optimal operative setting (inpatient ver- on polysomnography.50–52 Conversely, children
sus outpatient) for tonsillectomy.11,37 An increased who snore but are otherwise asymptomatic occa-
apnea-hypopnea index (AHI) and low oxygen satu- sionally have severe ventilatory disturbances on
ration nadir predict PRAEs.38–43 However, AHI and polysomnography.51 Pediatric polysomnography is
oxygen saturation nadir are not consistent predictors expensive, labor-intensive, and may not be readily
of PRAEs.44–46 There is disagreement regarding the available in all areas.
polysomnography parameter cutoffs that necessitate SAMBA does not recommend routine preopera-
inpatient monitoring following tonsillectomy.11,37 tive polysomnography before adenotonsillectomy
Severe OSA is defined as an oxygen saturation nadir in patients without symptoms of SDB or for those
<80% or an AHI ≥10.41–43 These values are practice- patients whose indication for surgery is recurrent ton-
derived and based on meta-analyses of observational sillitis (moderate SOE).
studies.
Although there is ongoing debate regarding the Is There a Minimum Age for Ambulatory
definition of severe OSA in children based on poly- Tonsillectomy With or Without Adenoidectomy in
somnography results, definitive criteria must be Children?
established to aid ambulatory anesthesiologists in Children <3 years of age may have increased peri-
making clinical decisions and identifying children operative risks associated with adenotonsillec-
who have an elevated risk of complications. This tomy.53–55 In this age group, the indication for surgery
can prevent unscheduled admissions or the need for is usually upper airway obstruction with OSA.54,56,57
increased medical attention. Complications can include dehydration and adverse
SAMBA recommends that children with severe OSA ventilatory events.
based on polysomnography results demonstrating an In 2019, The AAO-HNS Foundation released
oxygen saturation nadir <80% or an AHI ≥10 should updated clinical practice guidelines endorsed by the
not be scheduled at a freestanding ASC (high SOE). American Academy of Family Physicians, the American
Academy of Sleep Medicine, and the American Society
Who Should Have Polysomnography Before a of Pediatric Otolaryngology that recommend inpatient
Tonsillectomy With or Without Adenoidectomy? admission and monitoring for patients <3 years of age
Polysomnography before adenotonsillectomy is sug- undergoing adenotonsillectomy.11
gested for patients with conditions associated with an SAMBA recommends that children 3 years and
increased risk of upper airway obstruction or central older may undergo adenotonsillectomy at freestand-
apnea postoperatively. The AAO-HNS recommends ing ASCs (moderate SOE).
referral of high-risk children with suspicion of OSA
for polysomnography if they are <2 years of age or if INTRAOPERATIVE CARE
they exhibit any of the following: obesity, Trisomy 21, Is an Intravenous Induction Safer than an
craniofacial abnormalities, neuromuscular disorders, Inhalation Induction?
sickle cell disease, or mucopolysaccharidoses.11 The method of induction may impact the risk of peri-
For healthy patients without the above comorbidi- operative ventilatory events. Von Ungern-Sternberg et
ties, the utility of preoperative polysomnography is al58 aimed to identify factors associated with PRAEs.

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 E  NARRATIVE REVIEW ARTICLE  

PRAEs such as bronchospasm, laryngospasm, cough- for the use of ketorolac in patients having tonsillecto-
ing, desaturation, and airway obstruction occurred mies. McClain et al found a 5-day course of ketorolac
less frequently with intravenous induction. In a in adult patients having tonsillectomy or uvulopala-
randomized trial, Ramgolam et al59 found that an topharyngoplasty had no increase in postoperative
intravenous induction reduces the risk of periop- hemorrhage. Rabbani’s group found a single dose of
erative ventilatory adverse events in children with ketorolac in pediatric patients having tonsillectomies
certain respiratory symptoms compared to inhala- demonstrated no increase in hemorrhage.65,66 The
tional induction. A systematic review by Porter et al60 opioid-sparing effect of ketorolac is noncontroversial.
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revealed no significant difference in the occurrence SAMBA recommends that ketorolac in a dose of 0.5
of perioperative ventilatory adverse events between mg/kg up to 30 mg is acceptable for use at the end of
inhalation induction with sevoflurane and intrave- the case after hemostasis has been achieved as part of
nous induction with propofol in pediatric patients. multimodal pain management for pediatric patients
More evidence is needed to clearly define the periop- undergoing tonsillectomy, in consultation with the
erative risk differences for inhalation versus intrave- otolaryngologist (moderate SOE).
nous induction in pediatric patients. However, there
may be benefits for those practitioners who do not Does Dexmedetomidine Have Advantages in
frequently perform inhalation induction on pediatric Patients Having Adenotonsillectomy?
patients to utilize intravenous induction. Dexmedetomidine is used in patients having tonsil-
SAMBA recommends that providers utilize the lectomies for its sedative, anxiolytic, and analgesic
induction technique they are most familiar with and properties. Dexmedetomidine is indicated to reduce
recognizes that intravenous induction may be advan- the ventilatory depressant effects of opioids, mini-
tageous in patients with a history of airway reactivity mize emergence agitation, and maintain a patent
(low SOE). airway.67 However, there is concern that dexmedeto-
midine may increase emergence times and length of
Is Ketorolac an Acceptable for Pain Management stay in the PACU. Bellon et al,68 in a meta-analysis,
in Patients Having Tonsillectomies? demonstrated an opioid-sparing effect in children
The use of ketorolac in patients having tonsillec- with a >0.5 µg/kg bolus dose of dexmedetomidine,
tomy with or without adenoidectomy is controversial except in patients having adenotonsillectomies. Adler
because of the associated platelet effects mediated by et al67 evaluated patients having adenotonsillectomies
cyclooxygenase inhibition. One of the earliest stud- specifically and found that each 0.1 µg/kg of dexme-
ies investigating the use of ketorolac in tonsillectomy detomidine reduced the need for an oral-equivalent
patients had to be stopped due to the increased occur- dose of morphine by 0.02 mg/kg and increased the
rence of bleeding in patients receiving the drug.61 PACU stay by 0.7 minutes which was not statistically
However, further research has defined the safe use of significant. Franz et al documented a successful tran-
ketorolac, especially in pediatric patients. The Splinter sition toward minimal opioid use by using NSAIDs
et al61 study used ketorolac at 1 mg/kg doses at the and dexmedetomidine (1 µg/kg) in patients hav-
beginning of the case. Compared to their codeine ing adenotonsillectomies. They found an infrequent
group, those receiving ketorolac bled more. Since that need for rescue medications and no increased delay
time, there have been 3 meta-analyses with different in discharge.69,70 A 2017 meta-analysis demonstrated
findings. Lewis et al,62 in 2013 in a Cochrane review, a decrease in rescue analgesia with both bolus and
found that there was not strong enough evidence to infusions of dexmedetomidine when compared to
recommend nonsteroidal anti-inflammatory drugs placebo. The comparison of dexmedetomidine ver-
(NSAIDs) due to a nonsignificant increase in post- sus opioid was not statistically significant.71 Two
tonsillectomy hemorrhage, but NSAIDs significantly additional studies have opposite findings. Olutoye
reduced opioid use. In 2014, Chan and Parikh63 did et al72 showed that dexmedetomidine, 1 µg/kg, and
a Cochrane review that found adults were at risk for morphine, 0.1 mg/kg, were equipotent in decreasing
increased bleeding from ketorolac, but not pediat- the need for rescue analgesia without increasing the
ric patients. Finally, in 2021, Cramer et al64 broadly PACU length of stay. West et al,73 in a retrospective
reviewed NSAIDs and found that ketorolac had a review examining the association of dexmedetomi-
higher potential to cause bleeding than ibuprofen dine and PACU discharge, showed that there was just
or diclofenac, but results with all 3 drugs had wide under a 15-minute delay per µg/kg of dexmedetomi-
confidence intervals. The use of ketorolac at 0.5 mg/ dine given.
kg is supported to be safe with no increase in post- A dexmedetomidine bolus followed by an infusion,
tonsillar hemorrhage and a decrease in opioid use. The compared to a fentanyl bolus reduced emergence
risk of hemorrhage increases as the dose of ketorolac delirium to 5 and 15 minutes postadmission to the
increases. As research continues, there is more support PACU. There was no difference in the range of delirium

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 The Pediatric Patient for Ambulatory Tonsillectomy

scores.74 This contrasts with a 2013 Cochrane review adjuvants has been shown to have similar outcomes
of 5 articles with 438 patients that showed no advan- compared to the use of intraoperative opioids.83,84
tage of dexmedetomidine compared to the effects of Avoiding opioids or using the lowest doses may
fentanyl or morphine on emergence delirium because be prudent given the associated comorbidities of
the confidence intervals were too wide. The doses of SDB and OSA. Patients with severe OSA may ben-
dexmedetomidine ranged from 0.25 to 4 µg/kg in the efit significantly from a reduction in intraoperative
studies.75 Franz et al70 used 1 µg/kg of dexmedetomi- opioid use.69,84 Avoiding long-acting opioids is rec-
dine to maintain or decrease discharge times. ommended.85 Several studies have shown that post-
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SAMBA recommends that dexmedetomidine can operative pain scores and PACU durations are similar
be considered in patients likely to benefit from the in patients who received intraoperative opioids and
drug when balanced against possibly prolonged seda- those receiving nonopioid modalities.86,87 Opioid-free
tion (low SOE). anesthetics are associated with decreased postopera-
tive nausea and vomiting rates.87 The use of nonopioid
Do Supraglottic Airway Devices Have analgesics and anesthetic adjuvants for periopera-
Advantages During Tonsillectomies? tive pain control is highly recommended. Nonopioid
The use of a supraglottic airway (SGA) for tonsillec- adjuvants, including NSAIDs, dexmedetomidine, ket-
tomy with or without adenoidectomy has increased. amine, acetaminophen, and dexamethasone improve
Advantages of an SGA over an endotracheal tube pain control and decrease opioid requirements.10,87–89
(ETT) include increased OR efficiency due to ease and SAMBA recommends using opioid-sparing multi-
speed of placement,76–78 improved hemodynamic sta- modal analgesic techniques in patients having adeno-
bility during induction and emergence, and reduced tonsillectomies due to the unknown degree of OSA,
anesthetic requirements, including avoidance of neu- but there is inadequate evidence to support clinical
romuscular blockade.4 Studies of ventilatory compli- benefit of opioid-free techniques in pediatric popula-
cations comparing SGA and ETT are equivocal, with tions (moderate SOE).
some studies reporting a higher incidence of laryngo-
spasm and oxygen desaturations77 while others note Is Deep Extubation Safe After an
lower incidences of coughing, sore throat, and imme- Adenotonsillectomy?
diate postoperative pain78 and improved oxygen satu- An awake extubation following adenotonsillectomy
rations with the use of an SGA, especially in patients is often advised as the standard technique, given the
with respiratory infections.76 concern for postoperative airway obstruction and
While some studies noted decreased surgical ventilatory complications. This technique is recom-
visualization with SGA use in adenotonsillectomy,79 mended for children who are at increased risk of
other studies did not find limited surgical access,78,80 aspiration of gastric contents, those with concerns of
especially when reinforced or flexible SGAs were uti- a difficult airway, or children with a history of OSA or
lized.81 Disadvantages noted with the use of SGAs SDB because deep extubation may increase the inci-
are air leaks and environmental contamination with dence of postoperative airway obstruction.90–92
inhalational agents.82 There is a need to keep a low Studies evaluating deep extubation after adenoton-
fraction of inspired oxygen (Fio2) to reduce the risk of sillectomy have shown some advantages over awake
airway fires. The comorbidities of some patients hav- extubation without significant differences in compli-
ing adenotonsillectomies may require higher Fio2 to cation rates.92 The exception to this finding may be
prevent desaturation. in patients of lower weight (≤14 kg).90 Advantages
Failure rates of SGA use, as defined by the need to of deep extubation are a decreased incidence of
reposition or replace the device, range from 0.6% to coughing,91,93,94 decreased oxygen desaturations, and
11%.77,80 Risk factors associated with increased failure a reduced risk of perioperative adverse events in
rates of SGA are age, mode of ventilation (controlled patients with concomitant respiratory infections.91
versus spontaneous), and surgical experience with Most studies were done in tertiary care centers
the device.77,78 and support the decision for extubation technique to
SAMBA recommends that airway management be determined by provider experience and systems-
is based on patient characteristics and surgical and based supports such as appropriately trained PACU
anesthesia team expertise (low SOE). nursing staff.90 Additionally, there is evidence that
deep extubation with the patient recovering in a lat-
Are Intraoperative Opioids Advantageous and eral position instead of supine may decrease postex-
Safe for Patients Having Adenotonsillectomies? tubation ventilatory complications.95
Data support the use of multimodal analgesia dur- SAMBA recommends extubation techniques based
ing pediatric adenotonsillectomies. Avoidance of or on the expertise of the anesthesia team and patient
low-dose intraoperative opioids with multimodal factors (low SOE).

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 E  NARRATIVE REVIEW ARTICLE  

What Are the Differences Between Coblation patients who meet the selection criteria to have their
and Cautery Tonsillectomies? surgery done in an ASC. These patients will typically
Methods available for tonsillectomy include coblation be ASA PS I and II without significant comorbidities.
tonsillectomy, electrocautery tonsillectomy, conven- Postoperative ventilatory complications are the most
tional cold dissection tonsillectomy, ultrasonic scalpel common reason for intensive care monitoring and
tonsillectomy, and thermal welding tonsillectomy. prolonged hospitalization after adenotonsillectomy.100
The most commonly used techniques are coblation A large survey showed that the majority of pediatric
tonsillectomy and electrocautery tonsillectomy. deaths occur at home during sleep.101 A cross-sectional
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A systematic review by Aldamluji et al10 suggests analysis of the 2010 National Hospital Ambulatory
coblation techniques have slightly less postoperative Medical Care Survey of hospitals and ASCs for pedi-
pain during the first day compared to electrocautery atric patients undergoing tonsillectomy with or with-
techniques. out adenoidectomy found that when compared with
A systematic review by Pynnonen et al96 found less an inpatient cohort, the ambulatory adenotonsillec-
pain on postoperative day 1 with coblation tonsillec- tomy group was older and less likely to have OSA.102
tomy, but the difference was clinically insignificant. Children <3 years old or with severe OSA (AHI ≥10
By postoperative day 7, there appeared to be little or obstructive events/h, oxygen saturation nadir <80%,
no difference and a small increased risk of secondary or both) should be observed overnight after tonsillec-
bleeding with coblation. The evidence supporting tomy and therefore are not candidates for freestand-
these findings is of low or very low quality. ing ASCs.11
A systematic review and meta-analysis examined A recent retrospective study of children with OSA,
10 randomized controlled trials (RCTs) comparing without risk factors, undergoing ambulatory tonsil-
coblation tonsillectomy and electrocautery tonsillec- lectomy found that ventilatory events for all children
tomy and found that compared with electrocautery occurred immediately following extubation up to 3
tonsillectomy, coblation tonsillectomy may reduce hours postoperatively.103
intraoperative blood loss and postoperative rehabili- A prospective cross-sectional study of children
tation time, but there were no significant differences observed overnight after an adenotonsillectomy for
in the operation time, postoperative pain, and the OSA found that children tolerating room air within
incidence rate of postoperative complications com- 3 hours of surgery and passing a sleep room air
pared with electrocautery tonsillectomy.97 challenge were safe for discharge from a ventilatory
A prospective, randomized, single-blind study of standpoint regardless of age, obesity status, asthma
293 patients, comparing coblation and monopolar diagnosis, OSA, or AHI.104
extracapsular tonsillectomy, found shorter operative A cross-sectional analysis of New York databases
times and decreased secondary bleeding and cost with found significantly higher revisits after ambulatory
electrocautery tonsillectomy compared with coblation adenotonsillectomy when the surgery was late after-
tonsillectomy.98 A systematic review of 318,453 pediat- noon or evening or if the patient was discharged later
ric tonsillectomies of National Health System patients in the day. This information can be used when sched-
in England from 2008 to 2019 demonstrated an overall uling patients.105
increase in the use of coblation tonsillectomy from 7% to SAMBA recommends that patients meeting selec-
27%. Patients with cautery dissection were found to have tion criteria for tonsillectomy with or without ade-
a significantly higher rate of readmissions for bleeding noidectomy at an ASC may be discharged home after
and pain when compared with patients with coblation.99 demonstrating recovery from anesthesia and meeting
Based on the available low-quality evidence, there established discharge criteria (low SOE).
appears to be reduced secondary bleeding with elec-
trocautery tonsillectomy, and no difference in the
immediate postoperative outcomes with coblation Is it Acceptable to Administer Opioids in the
tonsillectomy or electrocautery tonsillectomy. PACU After Tonsillectomies?
SAMBA recommends that providers consider the A heightened risk of opioid-induced ventilatory
surgical technique when planning for bleeding risk depression makes the perioperative use of opioids in
(low SOE). children with OSA particularly challenging. Opioid
sensitivity is reported in children with OSA, with
POSTOPERATIVE CARE some studies demonstrating that children with OSA
What Is the Minimum Postoperative Observation require approximately half the opioid dose.106,107
Period for Children After Ambulatory Other investigators found that OSA was not associ-
Tonsillectomy With and Without Adenoidectomy? ated with significant differences in central ventila-
We specifically address the minimum recommended tory depression following a single dose of fentanyl
period in the PACU after adenotonsillectomy in (1 µg/kg).108

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 The Pediatric Patient for Ambulatory Tonsillectomy

By utilizing dexmedetomidine, NSAIDs, and 2013,114 and “contraindication” was added in 2017,115
regional anesthesia for pediatric ambulatory surger- highlighting the risk of codeine in postoperative pain
ies at their facility, Franz et al70 reported that perioper- management in children following tonsillectomy.
ative opioids were minimized without compromising SAMBA recommends ibuprofen and acetamino-
patient outcomes or discharge times. Other investiga- phen for postoperative pain after discharge from the
tors have proposed opioid-free techniques for ton- ASC (moderate SOE).
sillectomy in children.109 The incidence of adverse SAMBA recommends that clinicians counsel patients
events was similar between the intraoperative opioid- and caregivers on managing post-tonsillectomy pain as
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free and intraoperative opioid groups. However, no part of the perioperative education process and rein-
data suggest improved outcomes with opioid-free force this at the time of surgery.
techniques. SAMBA recommends avoiding the use of codeine
SAMBA recommends judicious use of opioid anal- due to safety concerns (high SOE).
gesics in the PACU, utilizing reduced doses of opioids
based on the severity of OSA (moderate SOE). CONCLUSIONS
Tonsillectomy is one of the most common pediatric
What Is the Optimal Postdischarge ambulatory surgeries, and in areas without a dedicated
Analgesic Plan for Pediatric Patients Having children’s hospital is likely to be managed by a general
Adenotonsillectomies? anesthesiologist and general otolaryngologist. It is this
Tonsillectomy in children can be associated with subset of practitioners who are continually looking for
significant pain that may be prolonged in up to guidance to safely manage these pediatric patients, par-
one-third of patients.110 The AAO-HNS Foundation ticularly in the presence of comorbidities. No guidelines
revised their pain management recommendations for for outpatient pediatric tonsillectomy have thus far been
patients having tonsillectomies in their most recent established due to a lack of high-quality data. National
guidelines.11 The updated guideline strongly recom- data pertaining to patient demographics, indications,
mends prescribing ibuprofen and acetaminophen and perioperative outcomes for pediatric ambulatory
instead of codeine and other opioids and emphasizes tonsillectomy are both outdated and lacking.
the importance of counseling caregivers about pain Though waiting for definitive evidence would
management. be ideal, in light of safe patient care, perfection may
NSAIDs are associated with altered platelet func- be the enemy of good enough. A lack of statistically
tion and theoretically increase the risk of bleeding significant data does not mean recommendations
after surgery. A randomized clinical trial by Diercks for safe practice should not be provided. Pediatric
et al111 in 2019 demonstrated that bleeding requiring ambulatory tonsillectomy is not without risk, and it
operative intervention occurred in 1.2% of those in is in the best interest of our patients and their families
the acetaminophen group and 2.9% in the ibuprofen that every practitioner has information available to
group. The Prospect Guidelines for postoperative inform their management and provide a basis for safe
pain management after tonsillectomy was published decision-making.
in 2021. After review of 226 RCTs, the authors recom- We acknowledge the low levels of evidence for
mend paracetamol and NSAIDs.10 The authors also many of the statements. Further research is indicated,
recommend intraoperative dexamethasone and opi- and a national survey of pediatric ambulatory sur-
oids for rescue.10 geries and outcomes and/or inclusion of tonsillecto-
Codeine is not appropriate to manage pain after mies in ACS National Surgical Quality Improvement
hospital discharge. There are several reported deaths Program (NSQIP) Pediatric would be of significant
following tonsillectomy related to ventilatory depres- benefit. SAMBA recommends further prospective
sion from excess dosing, and due to rare variations in studies to capture relative outcomes of the clinical
the liver cytochrome (CYP) 2D6 enzyme. Individuals benefit of anesthesia techniques and different tonsil-
who have more than 2 normal-function copies of the lectomy methods in pediatric populations undergo-
CYP2D6 gene (“ultrarapid metabolizers”) can metabo- ing tonsillectomy. E
lize codeine to morphine more rapidly and may expe-
rience the symptoms of a morphine overdose even DISCLOSURES
with therapeutic doses of codeine.112 Recent deaths Name: Marjorie P. Brennan, MD, MPH.
in children suggest that codeine and potentially other Contribution: This author helped with conceptualization, out-
opioids metabolized by the CYP2D6 pathway cannot line creation, literature review, writing-original draft prepara-
be considered safe analgesics for young children after tion, writing-reviewing and editing.
Name: Audra M. Webber, MD, FASA.
tonsillectomy, especially those with OSA.113 A Federal Contribution: This author helped with conceptualization,
Drug Administration Black Box warning was added literature review, writing-original draft preparation, writing-
to the drug label of codeine-containing products in reviewing and editing.

8   
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 E  NARRATIVE REVIEW ARTICLE  

Name: Chhaya V. Patel, MD. Levels of Evidence. Oxford Centre for Evidence-Based
Contribution: This author helped with literature review, writing- Medicine. [Link]
original draft preparation, writing-reviewing and editing. levels-of-evidence/ocebm-levels-of-evidence.
Name: Wanda A. Chin, MD. 14. Bohr C, Shermetaro C. Tonsillectomy and adenoidectomy.
Contribution: This author helped with literature review, writing- In Medical Management of the Surgical Patient: A Textbook
original draft preparation, writing-reviewing and editing. of Perioperative Medicine. StatPearls; 2023.
Name: Steven F. Butz, MD, SAMBA-F. 15. Mamie C, Habre W, Delhumeau C, Argiroffo CB, Morabia
Contribution: This author helped with literature review, writing- A. Incidence and risk factors of perioperative respiratory
original draft preparation, writing-reviewing and editing. adverse events in children undergoing elective surgery.
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Name: Niraja Rajan, MD, FAAP, SAMBA-F, FASA. Paediatr Anaesth. 2004;14:218–224.
Contribution: This author helped with contributed to concep- 16. Caetta A, Timashpolsky A, Tominaga SM, D’Souza N,
tualization, literature review, writing-original draft prepara- Goldstein NA. Postoperative respiratory complications
tion, writing-reviewing and editing. after adenotonsillectomy in children with obstructive sleep
This manuscript was handled by: Girish P. Joshi, MBBS, MD, apnea. Int J Pediatr Otorhinolaryngol. 2021;148:110835.
FFARCSI. 17. ASA Physical Status Classification System |
American Society of Anesthesiologists (ASA).
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 The Pediatric Patient for Ambulatory Tonsillectomy

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