Adenotonsillectomy remains one of the most commonly performed surgical procedures in children, particularly for the treatment of obstructive sleep apnea, recurrent throat infections, and breathing difficulties caused by enlarged tonsils and adenoids. While surgeons focus on removing the affected tissue, anesthesiologists must ensure that the patient's airway remains safe throughout the procedure.
For decades, endotracheal tubes (ETTs), also known as tracheal tubes, have been considered the standard approach for airway management during adenotonsillectomy. However, laryngeal masks (LMs) have emerged as a potential alternative, sparking debate among healthcare professionals regarding their safety, effectiveness, and impact on surgical outcomes.
A recently published systematic review and meta-analysis examined the available evidence from randomized controlled trials to compare laryngeal masks and tracheal tubes in patients undergoing adenotonsillectomy. The findings provide valuable insights into whether laryngeal masks can serve as a reliable alternative in modern pediatric and adult airway management.
A laryngeal mask airway is a supraglottic airway device designed to sit above the vocal cords rather than passing through them. Unlike an endotracheal tube, which requires insertion into the trachea, a laryngeal mask offers a less invasive method of ventilation.
Potential advantages of laryngeal masks include:
Despite these benefits, concerns remain regarding aspiration risk, airway protection, and the possibility of requiring conversion to tracheal intubation during surgery.
Researchers conducted a systematic review and meta-analysis of randomized controlled trials comparing laryngeal masks with tracheal tubes in adenotonsillectomy procedures.
The study searched major medical databases, including PubMed, Embase, and Cochrane, through January 2025. Six randomized controlled trials involving 765 participants met the inclusion criteria.
The researchers evaluated several important outcomes, including:
The primary goal was to determine whether laryngeal masks offered comparable safety and effectiveness to traditional tracheal intubation.
One of the most important conclusions from the analysis was that overall adverse respiratory events were similar between both airway management techniques.
Bronchospasm occurs when the muscles surrounding the airways tighten, making breathing difficult. The study found no statistically significant difference between patients receiving laryngeal masks and those receiving tracheal tubes.
Laryngospasm, a sudden closure of the vocal cords, is a serious concern during airway management. Researchers observed comparable rates between the two groups, indicating that the use of a laryngeal mask did not increase the likelihood of this complication.
Oxygen desaturation refers to a drop in blood oxygen levels. Again, the analysis found no meaningful difference between the two airway devices.
Postoperative coughing can affect patient comfort and recovery. The review demonstrated similar rates of coughing among patients managed with either airway approach.
Overall, the combined analysis of respiratory complications showed no significant safety advantage for either method.
While safety outcomes were largely comparable, researchers identified a significant difference in surgical duration.
Patients receiving laryngeal masks experienced surgeries that were approximately 3.35 minutes longer on average compared with those managed using tracheal tubes.
Although a few extra minutes may not seem substantial, this finding was statistically significant. Researchers suggested several explanations:
For busy surgical centers performing large volumes of adenotonsillectomies, even small differences in operating room time can influence efficiency.
One surprising finding involved blood aspiration rates.
Traditionally, many clinicians assume that tracheal tubes provide superior protection against aspiration because they physically enter the trachea. However, the review found lower rates of blood aspiration among patients receiving laryngeal masks.
Reported aspiration rates were:
Researchers proposed several possible explanations. Many pediatric adenotonsillectomies utilize uncuffed tracheal tubes, which may provide less effective sealing against blood contamination. In contrast, the laryngeal mask creates a seal around the laryngeal inlet that may help redirect blood away from the lower airway.
The authors emphasized that surgical techniques and patient factors could also influence these results.
A major concern when using laryngeal masks is the possibility that ventilation becomes inadequate, requiring conversion to tracheal intubation.
The analysis found a conversion rate of approximately 4.7%.
Most conversions were not linked to severe airway emergencies. Instead, they were often related to:
Importantly, conversions generally occurred in controlled circumstances, allowing clinicians to maintain patient safety throughout the procedure.
The debate between laryngeal masks and tracheal tubes has persisted for decades in otolaryngology and anesthesiology.
This analysis contributes valuable evidence because it focuses specifically on randomized controlled trials involving adenotonsillectomy procedures. The findings suggest that:
Ultimately, the choice of airway device should consider patient characteristics, surgeon preference, anesthesiologist experience, and institutional protocols.
Although the review provides important insights, several limitations should be acknowledged.
First, most participants were children, limiting the ability to generalize findings to adult populations.
Second, some included studies lacked detailed protocols, creating minor concerns regarding risk of bias.
Third, reporting standards for adverse events varied among studies, making direct comparisons more difficult.
Finally, only six randomized trials were available, highlighting the need for additional high-quality research.
Current evidence suggests that laryngeal masks offer a safe and effective alternative to tracheal tubes during adenotonsillectomy. Researchers found no meaningful differences in major respiratory complications such as bronchospasm, laryngospasm, coughing, or oxygen desaturation.
However, laryngeal masks were associated with slightly longer surgical times and a modest conversion rate to tracheal intubation. Interestingly, they also demonstrated lower rates of blood aspiration in the analyzed studies.
As airway management technology continues to evolve, future large-scale randomized trials will help further clarify which patients are most likely to benefit from each approach.
Marques BF, Figueiredo AM, Gómez SCQR, Teixeira GV. Laryngeal Mask in Patients Undergoing Adenotonsillectomies. European Annals of Otorhinolaryngology, Head and Neck Diseases. Available online April 27, 2026.
This blog is intended for educational and informational purposes only. It does not constitute medical advice, diagnosis, or treatment recommendations. Healthcare decisions should always be made in consultation with qualified medical professionals. The information presented here is a simplified interpretation of published research and should not replace professional clinical judgment or individualized patient care.
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