Laryngeal Mask Airway Use in Tonsillectomy

As one of the most common pediatric procedures performed in the U.S., tonsillectomy is typically among the first operations that junior otolaryngology residents learn (Int J Pediatr Otorhinolaryngol. doi: 10.1016/j.ijporl.2021.110691). Most of these cases rely on endotracheal intubation (ETT) for airway management, the longtime workhorse of the operating room. The laryngeal mask airway (LMA) is becoming more popular across different surgical applications, including tonsillectomy.

Some reported advantages of the reinforced LMA include reduced muscle relaxant use, laryngeal and vocal cord stimulation, and laryngoscopy need (The Laryngoscope. doi: 10.1002/lary.22458.). Post-operative outcomes, including bronchospasm, sore throat, and stridor, are decreased (Arch Otolaryngol Head Neck Surg. doi: 10.1001/archoto.2010.230) alongside decreased intra-operative fentanyl use, costs, and anesthetic requirements (Anesth Analg. doi: 10.1097/00000539- 199709000-00016). Patients using an LMA experience significantly shorter extubation times (Arch Otolaryngol Head Neck Surg. doi: 10.1001/archoto.2010.230). The LMA can impede oral surgical field visualization, however, and cause ventilation and oxygenation problems from leaking or kinking (Eur J Anaesthesiol. doi: 10.1097/ EJA.0b013e32833d69c6). Consequently, ETT remains widely used. There is increasing use of LMA for tonsillectomy in the literature; however, approximately 8.0% of cases convert to ETT intra-operatively, mainly for surgical access and positioning (J Otolaryngol Head Neck Surg. doi: 10.1177/19160216241263851). This report highlights tips from pediatric otolaryngologists worldwide, with the common goal of providing practical guidance to junior residents to enhance confidence in using this technology.

Materials and Methods

This report was part of a larger survey study assessing global tonsillectomy practice patterns. Our previous article, “Resident Pearls: Pediatric Otolaryngologists Share Tips for Safer, Smarter Tonsillectomies” (ENTtoday. https://tinyurl.com/55hd3x9d), offers candid advice for resident trainees who are just beginning to perform tonsillectomies. Our words of wisdom come from pediatric otolaryngologists who responded to a global survey conducted from April 4 to May 16, 2024. It was designed by five fellowship-trained pediatric otolaryngologists from Canada, the U.S., Australia, and England. The survey was conducted via a secure online platform hosted by Lawson Health Research Institute (J Biomed Inform. doi: 10.1016/j. jbi.2019.103208), and participation was voluntary, uncompensated, and anonymous. Two hundred ninety-three pediatric otolaryngologists proficient in reading and writing English were recruited through an international WhatsApp group, where identities were confirmed by group administrators. The final sample of participants was deemed representative of the target study population because it included a diverse range of countries of origin. Qualitative responses were collated into codes and themes through six systematic stages of thematic data analysis, as per Braun and Clarke (Qual Quant. doi:10.1007/s11135-021-01182-y), by two of the authors (G.S. and V.N.). Survey results were double-coded and reviewed, and inconsistencies were discussed to increase intercoder reliability.