Pain relief methods in pediatric ENT surgery

Why ENT surgery in children needs a special approach

Operations on the tonsils, adenoids, nasal septum, ears and sinuses in children are performed in reflexogenic zones, close to large blood vessels and the cranial cavities. This requires adequate pain relief, stable breathing and strict control of the child’s position on the operating table. That is why multicomponent endotracheal general anesthesia is considered the “gold standard” for most ENT operations in children.

Local anesthesia in ENT surgery: role and limitations

In Russia, local anesthesia has historically been widely used in ENT surgery, especially for adenoidectomy and tonsillectomy. Its role is now being reconsidered:

• Topical or infiltration anesthesia is used as a component of general anesthesia or for minor procedures (laser and radiofrequency operations in an outpatient setting)
• For major operations on the lymphoid ring of the throat and deep-lying structures, local anesthesia does not provide sufficient pain relief and neurovegetative protection, especially in children

In short, in children local anesthesia more often complements general anesthesia rather than serving as a standalone method for full ENT operations.

General anesthesia: combined endotracheal anesthesia

• Induction — by inhalation (a mask with an N₂O/O₂ gas mixture and a volatile anesthetic such as sevoflurane or isoflurane) or intravenously (propofol and others) — depending on the child’s age, venous access and the team’s experience
• Maintenance — inhalation anesthesia (N₂O:O₂ in various ratios with sevoflurane or isoflurane) or an intravenous propofol infusion, often combined
• Analgesia — provided by opioids (fentanyl as a bolus or infusion) and non-steroidal anti-inflammatory drugs
• Airway — tracheal intubation ensures free, controlled breathing and protects the airway from blood and secretions

This approach is considered the safest and most controllable for most ENT operations in children.

Mask inhalation anesthesia

For small, short procedures (for example, placing or removing a tympanostomy tube), mask anesthesia without intubation may be used. Short-acting inhaled anesthetics are used for up to 30 minutes, which suits brief procedures in children. However, in young children and when the risk of airway obstruction is higher, anesthesiologists increasingly prefer endotracheal anesthesia.

Intravenous pain relief regimens

A continuous propofol infusion with oxygen or a gas mixture (N₂O + O₂) makes it possible to perform long operations with a controlled depth of anesthesia. Opioids (fentanyl) are given as a bolus or infusion to provide a full analgesic component. Combining inhalation and intravenous anesthesia gives the flexibility to adapt to the length and complexity of the operation.

Premedication and prevention of postoperative pain and nausea

• Premedication — oral midazolam or intranasal dexmedetomidine, sometimes combined with other drugs, is used to reduce pre-operative stress and improve cooperation
• Postoperative pain relief — starts in the operating room: opioids, NSAIDs, paracetamol, regional blocks and local anesthetics are used
• Prevention of nausea and vomiting — antiemetics (metoclopramide, ondansetron and others) are given at induction and before the end of anesthesia

This multi-level strategy reduces the child’s discomfort after surgery and supports early recovery.

Safety and organizational requirements

• Observing the fasting period before surgery and individual planning of infusion therapy
• Full anesthesia equipment, a resuscitation kit and trained staff at the clinic
• Standardized monitoring during surgery (ECG, blood pressure, SpO₂, capnography, temperature)

This defines the modern standard of anesthetic care in pediatric ENT surgery.