Laryngeal Mask Airway Use in Tonsillectomy

The American Academy of Otolaryngology–Head and Neck Surgery 2019 Clinical Practice Guideline for Tonsillectomy in Children highlights the morbidity of tonsillectomy, including risks with anesthesia, prolonged throat pain, and financial costs (Otolaryngol Head Neck Surg. doi: 10.1177/0194599818801757). These factors are often at least partially attributed to ETT use, as studies have shown advantages with LMA, such as shorter induction and recovery times, along with reduced intraoperative airway pressure (Acta Clin Croat. doi: 10.20471/acc.2022.61.04.07). Our respondents identified that being under two years old is a predictive factor for LMA conversion to ETT. This is consistent with the literature, which suggests younger age is associated with increased odds of LMA failure, likely due to the smaller oropharynx size relative to the LMA, increasing malposition risk (Int J Pediatr Otorhinolaryngol. doi: 10.1016/j. ijporl.2012.09.021). This is consistent with other patient-related factors, including craniofacial abnormalities and overall smaller body size. Potential risks must be assessed on a case-by-case basis and thoroughly discussed with anesthesiology. This cooperation is crucial for successful LMA use during tonsillectomy (Aust J Otolaryngol. doi: 10.21037/ajo-20-77), as reflected in our responses, where numerous participants emphasized collaboration with anesthesia across multiple themes.

The Takeaway

• Choose the right patient: LMAs are not one-size-fits-all.
• Prioritize ventilation; convert promptly to ETT if there are concerns.
• Refine your setup: Gag, blade, and LMA positioning all matter.
• Practice intentionally: Treat LMA skills as integral to learning tonsillectomy.

Our study highlighted a series of concrete technical tips and a clear message for junior otolaryngology residents: Stick with LMAs long enough to get past the early learning curve. Respondents emphasized that the advantages of LMA use become increasingly apparent with growing familiarity and experience. As with any procedural skill, longitudinal practice and deliberate application of LMA techniques are likely to improve outcomes in carefully selected patients. The mechanical challenges that currently temper enthusiasm for LMAs may well diminish, both clinically and in the literature, as the approach becomes more widely adopted. With time, surgeons worldwide are likely to grow more comfortable with LMAs and their impact on surgical field visualization, provided that patient selection and indications remain thoughtful and evidence-informed. Further research is crucial to accurately assess the benefit–to–risk ratio of LMA compared to ETT, which is essential for incorporation into future guidelines, ensuring tonsillectomy remains safe and beneficial for pediatric patients. This piece is adapted from a larger survey study approved by the Western University Health Sciences Research Ethics Board. For more on the study’s methodology or to request supplementary data, contact the corresponding author.