Anesthetic outcomes in pediatric tonsillectomy: insights from the Palestinian experience

Abstract

Background

Despite advancements in anesthesia, the anesthetic outcomes in pediatric tonsillectomy remain largely underexplored, notably in resource-limited healthcare systems. This study aimed to assess the anesthetic outcomes in pediatric tonsillectomy, including induction-to-incision time and predictors of duration of surgery.

Methods

The study was conducted at one of the major surgical hospitals in the West Bank of Palestine, which is a tertiary referral center known for its comprehensive surgical and anesthetic services. The data were collected retrospectively from pediatric patients who underwent tonsillectomy with or without adenoidectomy in the period between 2021 and 2022. The data were collected using a standardized data collection form.

Results

Of the 238 pediatric patients included in this study, 231 (97.1%) were operated for adenotonsillar hypertrophy, and 7 (2.9%) were operated for recurrent/chronic tonsillitis. The mean age of the patients was 5.6 ± 3.1 years. Of the patients, 151 (63.4%) were male, 13 (5.5%) had an allergy to foods or drugs 13 (5.5%) had other comorbidities, and 21 (8.8%) had a past surgical history. Of the patients, 230 (96.6%) received propofol and 183 (76.9%) received fentanyl as anesthesia induction agents. The mean induction to incision time was 5.2 ± 1.1 min, and the mean duration of surgery was 26.4 ± 5.4 min. Of the patients, 53 (22.3%) received antibiotics during surgery. The induction to incision time was significantly longer for male patients (5.4 ± 1.3 vs. 5.0 ± 0.7, p-value = 0.022). The duration of surgery was significantly longer for female patients, 5 years and older, who had allergies, had chronic tonsillitis, and received antibiotics during the surgery. Multiple linear regression showed that longer duration of surgery could be predicted by being operated for recurrent/chronic tonsillitis (β = 0.15) and receiving antibiotics during the surgery (β = 0.13).

Conclusion

The findings of this study revealed that patient-specific factors influenced induction-to-incision time and duration of surgery. The findings of this study highlight the need for tailored preoperative assessment and individualized perioperative management to optimize resource utilization and improve surgical efficiency in resource-limited settings.

Background

Tonsillectomy, adenoidectomy, and adenotonsillectomy are the most commonly performed surgical procedures in children around the globe (Murto et al. 2017). Tonsillectomy refers to the surgical removal of tonsils, adenoidectomy refers to the surgical removal of adenoids, and adenotonsillectomy refers to the surgical removal of both tonsils and adenoids (Schneuer et al. 2022). These surgical procedures are often indicated for sleep-disordered breathing caused by adenotonsillar hypertrophies or malignancies, chronic or recurrent tonsillitis, adenoiditis, otitis media, and/or sinusitis with effusion (Han et al. 2023; Murto et al. 2017; Patel et al. 2014; Schneuer et al. 2022). While there are limited statistics on the number of procedures performed in the Palestinian practice, 559,900 ambulatory and 7100 inpatient tonsillectomies with or without adenoidectomy were performed in the USA in 2019 (Johnson et al. 2023).

In pediatric patients, tonsillectomy with or without adenoidectomy is performed under general anesthesia, and the patients are cared for by general or pediatric anesthesiologists (Brennan et al. 2024). Anesthesiologists select the appropriate anesthetic technique depending on several key factors, including the age of the pediatric patient, the presence of other comorbidities, and the planned surgical approach (Brennan et al. 2024; Ortega et al. 2022; Zeng et al. 2025).

Induction-to-incision time and duration of surgery are important metrics in assessing the efficiency of pediatric tonsillectomy (Albornoz et al. 2024; Edmonson et al. 2022; Spencer et al. 2025). Previous studies have shown that the indications and outcomes of tonsillectomy and adenotonsillectomy and outcomes of pediatric patients were affected by gender, race/ethnicity, and age (Han et al. 2023; Wikner et al. 2025). Although many studies have reported on tonsillectomy techniques and anesthetic management in high-resource environments, few studies were conducted to describe anesthetic outcomes in pediatric tonsillectomy, notably induction to incision time and the overall duration of surgery in resource-limited settings such as Palestine.

It is well-established that efficient operating room management is particularly critical in resource-limited healthcare settings (Neighbour et al. 2023). In pediatric patients, tonsillectomy with or without adenoidectomy is a fairly common surgical procedure. Currently, there is a gap in the literature concerning the anesthetic outcomes in pediatric tonsillectomy in the Palestinian practice, notably about the time from anesthesia induction to surgical incision and duration of surgery. Understanding the influence of patient demographic and health status factors, including age, sex, and allergy status can help anesthesiologists, surgeons, and other providers of perioperative care services tailor anesthesia protocols to the individual needs of the patients (Han et al. 2023). In addition, this focus could also improve the safety of the patients and the efficiency of operating room management where resources and standardized protocols are limited.

This study was conducted to assess the anesthetic outcomes of pediatric tonsillectomy in the Palestinian practice. The study assessed the anesthesia induction techniques, airway management strategies, time from anesthesia induction to incision, and predictors of surgical duration and outcomes. The findings of this study may provide actionable insights that can help improve the outcomes of the patients scheduled to undergo tonsillectomy in resource-limited settings.

Methods

Study design and settings

The study was conducted at one of the major surgical hospitals in the West Bank of Palestine, which is a tertiary referral center known for its comprehensive surgical and anesthetic services. The data were collected retrospectively from pediatric patients who underwent tonsillectomy with or without adenoidectomy in the period between 2021 and 2022. The study adhered to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement. Adherence to the statement is shown in Supplementary Table S1.

Patients

The study sample was all pediatric patients (under 18 years old) who underwent tonsillectomy with or without adenoidectomy under general anesthesia. The patients were eligible for inclusion in the study when they had complete anesthesia and surgical records. The patients with incomplete or missing data were excluded. The electronic surgical database of the hospital was used to search for and identify the pediatric patients to be included in the study. Additionally, a manual review of the anesthesia records was also conducted. Moreover, recovery notes, discharge summaries, and postoperative appointment notes of the patients were also reviewed to identify any documented postoperative complications.

A total of 238 pediatric tonsillectomy cases with complete anesthesia and surgical records were identified through the electronic database of the hospital. In this study, the tonsillectomies were performed using the cold steel technique. This conventional technique is known for its effectiveness and safety in minimizing intraoperative blood loss (Lieberg et al. 2019).

Variables and data collection

A standardized data collection form that was developed based on a thorough literature review of the relevant studies was used (Allford & Guruswamy 2009; Brennan et al. 2024; D'Eredita 2010; Huang et al. 2024; Lee & Hache 2022; McGuire & Doyle 2021; Mitchell et al. 2019; Schneuer et al. 2022; Yang et al. 2022). The data collection form is provided in Supplementary Table S2. The data collection form consisted of three sections. The first section collected the demographic and health variables of the pediatric patients, including age, height, weight, and sex. The body mass index was calculated based on weight and height. In addition, this section also collected information on the presence of known food and drug allergies, comorbidities, past surgical history, and chronic medications. The second section collected information on the indication for tonsillectomy, preoxygenation, laryngoscopy, and the technique used to prevent aspiration of gastric contents. This section also collected the agents used for induction and maintenance of anesthesia, induction time, induction of anesthesia to incision time, agents administered to achieve adequate muscle relaxation, agents administered to achieve intraoperative analgesia, and antibiotics administered to reduce the risk of postoperative infections. The third section collected information on the duration of surgery, intraoperative systolic and diastolic blood pressure, heart rate, and amount of intraoperative normal saline administered. The data collection form was reviewed by surgeons (n = 3), anesthesiologists (n = 2), and a pharmacologist for content and face validity.

Statistical analysis

The data were entered into MS Excel sheets and then transferred into IBM SPSS v.21.0 for statistical analysis. Categorical data were expressed as frequencies (n) and percentages (%) and continuous data were expressed using means and standard deviations (SD). Differences in induction-to-incision time and duration of surgery in relation to the variables of the patients were assessed using t-tests. To control potentially confounding variables, the variables that were associated with the t-tests were included in a multiple linear regression model. Goodness-of-fit was assessed through a statistically significant R². The absence of multicollinearity issues was indicated by tolerance values of above 0.2 and variance inflation factor values of less than 5. The effect size of each indicator that represented how strongly the independent variable was associated with the dependent variable was assessed using the standardized coefficients (β).

Ethical approval

This study was conducted in adherence to the national and international ethical principles including those in the Declaration of Helsinki. Ethical approval was obtained from the Institutional Review Board (IRB) of An-Najah National University. Additional approvals were also obtained from the Office of Health Education of the Ministry of Health for governmental hospitals, and approvals from the managers of each private hospital were also obtained. The data was collected anonymously, and no information leading to the identification of the patient was made public.

Results

Characteristics of the patients

Of the 238 pediatric patients included in this study, 231 (97.1%) were operated for adenotonsillar hypertrophy, and 7 (2.9%) were operated for recurrent/chronic tonsillitis. The mean age of the patients was 5.6 ± 3.1 years. Of the patients, 151 (63.4%) were male, 13 (5.5%) had an allergy to foods or drugs 13 (5.5%) had other comorbidities, and 21 (8.8%) had a past surgical history. The demographic characteristics, past medical history, and past surgical history of the patients are shown in Table 1.

Table 1 Demographic characteristics, past medical history, and past surgical history of the patients

Preparation, airway management approach, induction and maintenance of anesthesia, surgery, and recovery of the patients

Preparation, airway management approach, induction and maintenance of anesthesia, surgery, and recovery of the patients are detailed in Table 2. In this study, all patients (100%) received preoxygenation before induction of anesthesia as an important component of airway management to improve oxygen reserves and prevent hypoxemia during episodes of apnea. A McGRATH® MAC video laryngoscope which used a Macintosh-style blade with video assistance to visualize the larynx in all patients and oral tracheal intubation was used to maintain open airways. The cricoid pressure technique was used to prevent aspiration of gastric contents in 2 (0.8%) patients. Of the patients, 230 (96.6%) received propofol and 183 (76.9%) received fentanyl as anesthesia induction agents. The mean induction to incision time was 5.2 ± 1.1 min, and the mean duration of surgery was 26.4 ± 5.4 min. Of the patients, 53 (22.3%) received antibiotics during surgery. At the end of the surgery, all the patients were discharged to the post-anesthesia care unit. As a standard of care, all patients received postoperative antibiotics and analgesics. In this study, 1 (0.4%) patient returned with bluish discoloration of the left upper eyelid.

Table 2 Preparation, airway management approach, induction and maintenance of anesthesia, surgery, and recovery of the patients

Association between induction to incision time and variables of the patients

The induction to incision time was significantly longer for male patients. Age, allergy status, past medical and surgical history, indication for surgery, and receiving antibiotics during the surgery were not associated with induction-to-incision time. Associations are shown in Table 3.

Table 3 Association between induction-to-incision time and variables of the patients

Association between duration of surgery and variables of the patients

The duration of surgery was significantly longer for female patients, 5 years and older, who had allergies, had chronic tonsillitis, and received antibiotics during the surgery. Differences are shown in Table 4.

Table 4 Association between duration of surgery and variables of the patients

To control confounding variables, the variables that were significantly associated with the univariate analysis were included in a multiple linear regression model. The model showed that a longer duration of surgery could be predicted by being operated on for recurrent/chronic tonsillitis (β = 0.15) and receiving antibiotics during the surgery (β = 0.13). These associations are shown in Table 5.

Table 5 Factors predicting duration of surgery

Discussion

Historically, tonsillectomy was primarily indicated for children suffering from recurrent/chronic infections, such as frequent episodes of tonsillitis (Han et al. 2023; Huoh et al. 2021). In recent years, there has been a significant shift in clinical practice. Today, an increasing number of children undergo tonsillectomy with or without adenoidectomy mainly because of obstructive symptoms, including overt obstructive sleep apnea, obstructive sleep-disordered breathing, and habitual snoring, which are attributable to adenotonsillar hypertrophy (Albornoz et al. 2024; Han et al. 2023; Huoh et al. 2021; Patel et al. 2014). This shift in clinical practice could be attributed to the deeper understanding of how untreated adenotonsillar hypertrophies contribute to cardiovascular diseases, neurocognitive, and developmental issues. Thus, highlighting the need for timely surgical interventions.

In this study, the vast majority of the pediatric patients underwent tonsillectomy for adenotonsillar hypertrophy. This might reflect a contemporary practice that aligns with the international shift in clinical practice by prioritizing surgical management of obstructive sleep-disordered breathing disorders over management of recurrent/chronic tonsillitis. The trends reported in this study are currently supported by the latest international guidelines and align with the global standards in pediatric otolaryngology.

In this study, all pediatric patients underwent a standardized anesthetic protocol that involved preoxygenation before induction of anesthesia. Airway management was then secured using oral tracheal intubation via a MAC video laryngoscope. This should have ensured accurate tube placement through direct visualization of the larynx. Previous studies have reported difficult laryngoscopy among pediatric patients (Stein et al. 2023; Takeuchi et al. 2023); however, in this study, no instances of difficult airways were reported. This might have indicated effective airway management among the cases included in this study.

Many previous studies have reported on the impact of different anesthetic regimens on the postoperative outcomes and recovery of pediatric patients who underwent tonsillectomy (Albornoz et al. 2024; Brennan et al. 2024; D'Eredita 2010; McGuire & Doyle 2021; Mitchell et al. 2019; Ortega et al. 2022; Yang et al. 2022; Zeng et al. 2025). Earlier studies have reported that propofol, sevoflurane, and halothane caused less irritation to the airways compared to thiopental and desflurane (Bangera 2017; Hatcher & Stack 1999). Therefore, propofol, sevoflurane, and halothane were preferred for pediatric tonsillectomy. In this study, propofol was used for anesthesia induction, rocuronium was used for neuromuscular blockade, and sevoflurane was used for the maintenance of anesthesia. These practices align with international guidelines and recommendations on pediatric tonsillectomy. These guidelines and recommendations were developed to reduce the incidence of postoperative nausea and vomiting compared to regimens relying on agents such as isoflurane (Albornoz et al. 2024; Brennan et al. 2024; Han et al. 2023; Höhne 2014). Furthermore, the use of lidocaine, morphine, and pethidine should have provided adequate pain control and should have allowed a faster return to oral feeding while reducing the risks of bleeding, infection, and other complications after the surgery. These findings emphasize the need for the adoption of standardized protocols, particularly those focused on anesthetic techniques, which are often lacking in lower-middle-income countries, to improve clinical outcomes and recovery time after surgery in children with pediatric tonsillectomy.

The findings of this study showed that the induction-to-incision time was significantly higher among male patients compared to female patients. Although more studies are needed to fully illustrate the mechanisms behind this difference, the effectiveness and speed of airway management might be influenced by subtle physiological or anatomical differences between male and female patients (Han et al. 2023; Klabusayova et al. 2022; Krishna et al. 2018; Opfermann et al. 2023). In addition, variations in airway dimensions or tissue composition might lead to a slightly more challenging intubation process in males. Moreover, variations in the levels of cooperation between male and female patients could also affect the transition from induction of anesthesia to surgical incision. Understanding the impact of these nuances might have practical implications on tailoring anesthesia induction protocols used for male patients to improve the efficiency and allocation of resources during airway management in pediatric tonsillectomy.

In this study, the duration of surgery was associated with female sex, being 5 years or older, allergy, being operated on for recurrent/chronic tonsillitis, and receiving antibiotics during the surgery. Regression analysis showed that a longer duration of surgery could be predicted by being operated on for recurrent/chronic tonsillitis and receiving antibiotics during the surgery. Although the literature did not report extensively on the sex- and age-related differences in surgical duration for pediatric tonsillectomy, these differences might be explained by sex- and age-related anatomical or compositional variations in tonsillar size, degree of vascularity, and tissue density (Han et al. 2023; Husman et al. 2025; Stanisce et al. 2018; Yoon et al. 2022). Moreover, the presence of allergy might reflect persistent inflammation of the tonsillar tissues (De Corso et al. 2021; Funakoshi et al. 2021). Inflammation can result in edematous and hyperemic tissues that are more fragile and prone to bleeding. Similarly, patients with recurrent/chronic tonsillitis can develop fibrotic changes and scarring as a result of the long-standing inflammation. Furthermore, receiving antibiotics during surgery could be a marker of pronounced inflammation. Together, sex-, age-, and inflammation-related variations can make dissecting and maintaining hemostasis more technically challenging which might necessitate more cautious surgical maneuvers and meticulous hemostatic control. These findings might indicate that surgeons might need to tailor their surgical maneuvers and techniques to the individual needs of the patients.

In contrast to the limited data on anesthesia-related complications in tonsillectomy within Palestinian practice, our retrospective review did not reveal any adverse respiratory events or complications in the operating room or recovery area. This finding is consistent with recent evidence that modern anesthetic protocols that are characterized by the use of intravenous induction agents, non-opioid adjuncts, and multimodal analgesia techniques were shown to significantly reduce common complications such as postoperative nausea, vomiting, and respiratory depression (Albornoz et al. 2024; Bangera 2017; Brennan et al. 2024; Han et al. 2023; Huoh et al. 2021; Husman et al. 2025; McGuire & Doyle 2021). A previous study demonstrated that opioid use increases the incidence of postoperative nausea and vomiting, delayed removal of the airway device, and respiratory depression (Kim et al. 2017). However, current strategies emphasize opioid-sparing protocols that have been shown to mitigate these risks. These findings underscore the advantages of adopting integrated, evidence-based anesthesia practices to enhance patient safety and recovery in resource-limited settings.

Strengths of the study

This study has a number of strengths. First, this was the first assessment of anesthetic outcomes in pediatric tonsillectomy in the Palestinian practice. Few studies were conducted in resource-limited settings, particularly on the effects of various anesthetic techniques, airway management, and induction agents on the outcomes of pediatric tonsillectomy. Second, the data were collected using a detailed and standardized data collection form. This form allowed the collection of and description of detailed demographic, health, and anesthetic outcomes in pediatric tonsillectomy performed in the Palestinian practice. Third, the data collected allowed describing the anesthetic and airway management protocols, including the use of intravenous propofol for induction, rocuronium for muscle relaxation, and sevoflurane for maintenance of anesthesia. Fourth, the study focused on assessing operative metrics, including induction-to-incision time and duration of surgery. In addition, the study also assessed the impact of patient-specific factors, including demographics and health characteristics on these metrics. Finally, rigorous statistical methods, including univariate analysis and multiple linear regression, were used to identify the factors that can be used to predict the operative metrics. Therefore, this should have provided actionable insights for optimizing intraoperative management and improving patient outcomes.

Limitations of the study

This study had some limitations that should be acknowledged. First, the study was conducted in a retrospective design. This design could be associated with selection bias and limited ability to establish causal relationships. Second, the data were collected from a single center over 2 years. This could have limited the generalizability of the findings to the entire population of pediatric patients who underwent tonsillectomy in different settings. Third, details of the immunological markers, including immunoglobulin E (IgE) or eosinophil counts were not systematically documented. The lack of these important data could have limited a wider understanding of the underlying mechanisms of allergy. Fourth, while this study assessed the immediate and short-term complications, long-term complications were not assessed. Finally, the observed association between intraoperative antibiotic administration and prolonged surgical duration may be confounded by the underlying case complexity and increased inflammatory state, suggesting the need for prospective studies to better clarify these relationships.

Conclusion

In conclusion, the findings of this study revealed that patient-specific factors influenced induction-to-incision time and duration of surgery. The induction-to-incision time was significantly longer for male patients and the duration of surgery could be predicted by being operated on for recurrent/chronic tonsillitis and receiving antibiotics during the surgery. The findings of this study highlight the need for tailored preoperative assessment and individualized perioperative management to optimize resource utilization and improve surgical efficiency in resource-limited settings. Future studies are needed to understand the underlying mechanisms driving these differences and to further refine these management protocols.