Evaluation of the effect of the mouth gag use on optic nerve sheath diameter of pediatric patients undergoing tonsillectomy or Adenotonsillectomy: An observational study

Abstract

Background: A mouth gag is usually used during tonsillectomy and adenotonsillectomy surgeries, cleft palate repair, obstructive sleep apnea surgery, and intraoral tumor excision. The placement of the gag causes hemodynamic changes similar to laryngoscopy. The aim of this study was to evaluate the effect of mouth gag placement on the optic nerve sheath diameter (ONSD) of pediatric patients. The secondary aim was to assess the relationship between neck extension and changes in ONSD. Methods: The trial was prospectively registered to the Australian New Zealand Clinical Trials Registry (Trial ID: ACTRN12618551291) on 12.04.2018. This prospective, observational study was performed in a tertiary university hospital operating room between 01.05.2018-01.07.2018. Thirty-five children aged < 18 years, with ASA I status, who were scheduled for tonsillectomy and adenotonsillectomy surgeries were prospectively included in the study. Measurements of ONSD were performed (T0) after induction of anesthesia, (T1) after endotracheal intubation, (T2) after mouth gag placement, and (T3) 20 min after mouth gag placement. After the mouth gag was placed and the head was positioned for surgery, the degree of neck extension was calculated. Results: All participants completed the study. There were significant differences in ONSD values at time points T1, T2, and T3 (p < 0.001, CI:-0.09,-0.05; p < 0.001, CI:-0.09,-0.05; p < 0.001, CI:-0.05,-0.02; respectively). The maximum increase in ONSD was after intubation (0.69 ± 0.06 mm) and immediately after mouth gag placement (0.67 ± 0.07 mm). ONSD values continued to increase 20 min after gag placement (0.36 ± 0.04). There was no relation between the degree of neck extension and ONSD values (β = 0.63, p = 0.715). Conclusions: The use of a mouth gag causes significant increases in ONSD measurements of children. Therefore, attention to the duration of mouth gag placement should be considered during surgery. Trial registration: The trial was prospectively registered to the Australian New Zealand Clinical Trials Registry (Trial ID: ACTRN12618551291) on 12.04.2018.