Laryngeal Mask Airway Use in Tonsillectomy

Technical Aspects of LMA Use

Technical complications with LMAs in pediatric tonsillectomy often stem from how the device interacts with the mouth gag and other hardware rather than from the LMA itself. Surgeons stressed the importance of allowing independent movement of the gag and LMA: “Do not move the LMA when inserting the gag. Make sure the two can move independently before opening that gag. Try a different-sized blade (usually smaller) for the gag. Try a half-size larger LMA.” Others recommended modifying the setup to prevent unintended advancement of the device: “Go a size smaller on your tongue blade than you would with a right-angle tube. The material on the [flexible] LMA tubing is quite soft and binds on the tongue blade as you insert it—you can end up pushing the LMA further in than you want. Insert the gag, then tug gently on the tubing to reseat the LMA before ratcheting open the gag. Use an endoscope for the adenoidectomy: The extra space occupied in the pharynx by the LMA can mean that you need to retract the palate tighter to get an adequate view with a mirror. Another win for endoscopes.” A further pearl was to minimize fixation-related displacement: “Use a flexible LMA and don’t tape it in place. Pull back on it gently so it doesn’t get pushed in when the mouth gag goes in.”

Building LMA Confidence

Just as competence in tonsillectomy comes only with repetition, comfort with LMAs is built the same way. One surgeon’s advice was simple: “Just do it—you’ll get used to it! It improves theatre utilization. Switch to ETT if any issues to avoid wasting time— this is around 1%.” Another emphasized the learning curve: “Need to have done about 10 to get comfortable with LMA positioning and Boyle Davis positioning. Don’t give up immediately on the first few attempts.” And in a nod to the team nature of airway management, one respondent added, “Wish my anesthetist could answer this.”

Discussion

Beyond learning tonsillectomy, residents must learn to adapt to the evolving landscape of ENT surgery, embracing new techniques and approaches that can improve outcomes for both patients and institutions. Despite the introduction of the LMA in adenotonsillectomy in 1998, use remains limited due to concerns over limited surgical access and ventilation challenges with mechanical components (Anesthesiol Clin. doi: 10.1016/j.anclin.2010.07.005). These issues were reflected in our study, where only 14.4% of respondents expressed a preference for LMA over ETT in tonsillectomy. Otolaryngologists who use it regularly shared favorable experiences with the LMA, particularly with continued practice, and provided practical recommendations for trainees to effectively incorporate this tool.