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.

Of the 132 total participants (45.1% response rate), 19 respondents (14.4% of respondents) signified that they prefer to use LMA, and answered the open-ended question, “If you use LMA during tonsillectomy, please describe situations where you would convert to endotracheal intubation/start with endotracheal intubation?” Sixteen respondents answered, “If you use LMA during tonsillectomy, please share any tips/tricks/ pearls,” and 1.5% of respondents preferred another airway management method, with the remaining majority using ETT.

With the aim of offering practical, conversational guidance to junior residents, while reflecting the evolving landscape of ENT surgery and fostering lifelong learning, four central themes emerged: choosing the right patient for an LMA, navigating airway pitfalls with LMAs, technical aspects of LMA use, and building LMA confidence.

Choosing the Right Patient

When it comes to LMAs in pediatric tonsillectomy, the first decision is not how to place one, but whether you should use one at all. Seasoned surgeons repeatedly flagged red-flag scenarios in which an LMA can quickly become the wrong choice: “less than two-year age; microstomic syndromes; chronic lung disease,” one surgeon cautioned. Another emphasized avoiding LMAs in children “under two years; respiratory disease; recent viral URTI; reflux,” while others pointed to “very small kids; craniofacial anomalies; severe obesity” as situations that tip the balance toward an endotracheal tube instead. Age and experience matter too; one respondent noted that in “age less than three, syndromic” patients, especially when “a junior resident [is] just learning tonsillectomy,” an ETT offers more reliable exposure and control. It is always important to consider the preference and familiarity of the anesthesiologist as well.

Navigating Airway Pitfalls with an LMA

Navigating airway pitfalls with an LMA means knowing exactly when to change course. Seasoned surgeons stressed that failure to “seat or ventilate appropriately” should never be ignored; it is the cue to reassess rather than push ahead. Their advice was clear: “Switch to endotracheal intubation if you encounter ventilation issues. Otherwise, continue with LMA.” Another pearl was to let the anesthesiologist’s comfort guide your next move: “If [the] anesthetist is not happy with ventilation or if the gag is obstructing [the] LMA,” it is time to abandon the device and secure the airway with an ETT. Ventilation issues addressed were commonly attributed to technological challenges of the LMA itself, such as mechanical compression of the device or epiglottic displacement, as reflected in the literature (Arch Otolaryngol Head Neck Surg. doi: 10.1001/ archoto.2010.230; J Otolaryngol Head Neck Surg. doi: 10.1177/19160216241263851). Anesthetic techniques, including inadequate depth of anesthesia, may contribute by causing reflex laryngeal closure upon mouth gag opening (Can J Anaesth. doi: 10.1007/BF03009607).

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.

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.

 

 

 

 

 

 

Ms. Spencer is a fourth-year medical student at Queen’s University School of Medicine in Kingston, Ontario. Mr. Nanthakumar is a fourth-year medical student at Queen’s University School of Medicine in Kingston, Ontario. Ms. Wilson is a research associate for the division of paediatric surgery at the Children’s Hospital, London Health Sciences Centre in London, Ontario. Mr. Davidson is the research coordinator for the division of paediatric surgery at the Children’s Hospital, London Health Sciences Centre in London, Ontario. Dr. Strychowsky is a pediatric otolaryngologist and division chief of pediatric otolaryngology at the Children’s Hospital, London Health Sciences Centre, and associate professor at the Schulich School of Medicine and Dentistry at Western University in London, Ontario. Dr. Bhargava is a pediatric otolaryngologist at Sheffield Children’s Hospital in the U.K., senior clinical lecturer at the University of Sheffield Faculty of Health, a visiting researcher at the Advanced Food Innovation Centre at Sheffield Hallam University, and co-director of SMELL (Sheffield cheMosensory Exploratory Laboratory). Dr. Lawlor is an assistant professor at Harvard Medical School, an attending pediatric otolaryngologist at Boston Children’s Hospital, an editor at JAMA Otolaryngology–Head and Neck Surgery, and chair-elect of the Young Physicians Section of the Academy of Otolaryngology–Head and Neck Surgery. Dr. Burns is a pediatric otolaryngologist at Queensland Children’s Hospital in Brisbane, Australia, senior lecturer in otolaryngology at the University of Queensland, incoming president of the Australian and New Zealand Society of Paediatric Otolaryngology, and editor in chief of the Australian Journal of Otolaryngology. Dr. Fowler is a general otolaryngologist at the Cape Breton Regional Hospital in Sydney, Nova Scotia, and an assistant professor in the department of surgery at Dalhousie University in Halifax, Nova Scotia. Dr. Graham is a pediatric otolaryngologist at the IWK Health Centre, and associate professor at Dalhousie University, both in Halifax, Nova Scotia, and a Triological Society fellow.