Pediatric Tonsillectomy & Adenoidectomy

About this case

A 6-year-old with polysomnography-confirmed severe OSA presents for tonsillectomy and adenoidectomy, then returns to theatre bleeding. The parent declines premedication, so the case tests communication as well as clinical management, and the second half is effectively a full-stomach emergency.

Key clinical features

• Severe OSA

  PSG-confirmed AHI 42 — narcotic sensitivity

• Father Refuses Premed

  No oral midazolam — manage separation anxiety

• Post-Op Hemorrhage

  Swallowed blood = full stomach for return to OR

• Failure to Thrive

  18 kg at age 6 — chronic hypoxemia from OSA

What the examiner is testing

• How severe OSA changes your analgesic plan, and whether you can explain the sensitivity rather than just naming a drug to avoid.
• Managing separation anxiety without pharmacological premedication, including how you involve the parent.
• Recognition that a post-tonsillectomy bleed presents as a full stomach because of swallowed blood.
• Your assessment of hypovolaemia in a child, where the usual signs appear late.

Where candidates lose points

• Planning opioid dosing as though for a child without OSA.
• Treating the return to theatre as a repeat of the first anaesthetic rather than an aspiration-risk emergency.
• Missing the significance of the growth failure as a marker of chronic disease severity.

How it is scored

Every BoardSim case is scored across the same five phases — pre-operative evaluation, anaesthetic plan, intra-operative management, crisis management, and emergence — for a total of 100 points, with a pass set at 70 and no missed critical action. You receive a written report against each phase rather than a single number. Read the scoring methodology.