BJA Education, 20(6): 184e192 (2020)
doi: 10.1016/j.bjae.2020.02.007
Matrix codes: 1H02,
2D02, 3A02
Paediatric adenotonsillectomy, part 1: surgical
perspectives relevant to the anaesthetist
K.T. Murto1,*, J. Zalan2 and J-P. Vaccani1
1
Children’s Hospital of Eastern Ontario, Ottawa, ON, Canada and 2Kingston Health Sciences Centre,
Kingston, ON, Canada
*Corresponding author: Kmurto@cheo.on.ca
Learning objectives
By reading this article, you should be able to:

Distinguish between obstructive sleep-
disordered breathing and obstructive sleep
apnoea (OSA) syndrome.

Describe the anatomical and neuromotor endo-
types of airway causing OSA in children.

Compare the indications, efficacy, recovery and
morbidity of tonsillotomy with tonsillectomy.

Discuss the risk factors for persisting OSA after
tonsillectomy in children.
Kimmo Murto MD FRCP is a paediatric anaesthetist working at the
Children’s Hospital of Eastern Ontario (CHEO) and an associate
professor at the Department of Anesthesiology and Pain Medicine,
University of Ottawa. He is past chair of the paediatric committee of
the Society of Anesthesia and Sleep Medicine. His research interests
include care of children undergoing tonsillectomy.
Julie Zalan MD FRCPC is an anaesthetist with specialty training in
paediatrics working at Kingston Health Sciences Centre and an as-
sistant professor at the Department of Anesthesiology and Periop-
erative Medicine, Queen’s University, Kingston.
Jean-Philippe Vaccani MD FRCPC is a paediatric otolaryngologist
working at CHEO, and an associate professor and vice-chair of ed-
ucation at the Department of OtolaryngologyeHead and Neck Sur-
gery, University of Ottawa. He has published previously on
paediatric obstructive sleep apnoea.
Accepted: 21 February 2020
© 2020 British Journal of Anaesthesia. Published by Elsevier Ltd. All rights reserved.
For Permissions, please email: permissions@elsevier.com
Advance Access Publication Date: 25 April 2020
Key points

Obstructive sleep apnoea (OSA) syndrome is a
multiorgan systemic inflammatory condition.

Obstructive sleep-disordered breathing is the
most common indication for adenotonsillectomy
(AT).

Overnight oximetry can diagnose OSA in
children.

There is no consensus for the indications,
approach or technique of AT to treat OSA.

Adenotonsillectomy normalises OSA sleep study
variables in approximately 80% of children; the
long-term treatment benefits of AT for OSA and
sore throat are unclear.
Adenotonsillectomy (AT) is one of the most common surgeries
performed in children worldwide. Obstructive sleep-
disordered breathing (oSDB), a spectrum in which obstruc-
tive sleep apnoea (OSA) is an extreme form, is the main indi-
cation for AT and is typically performed as an outpatient.
More than 530,000 children undergo AT each year in the USA,
representing 16% of all paediatric surgeries. The number of
ATs in the USA is 1.5e3 times that of other countries,
including Canada and the UK. Within the USA, the rates of AT
can vary up to four-fold.1 As a common surgery associated
with a high degree of variability in both practice and out-
comes, evidence-based standardised care is desirable.
A lack of consensus on the criteria and severity of disease
warranting surgery may explain the variation in practice. In
the case of OSA, polysomnography (PSG) is the gold standard
for diagnosis, but there is no consensus on the degree of
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