For Kids Having Tonsils Out, Is a Laryngeal Mask Safer Than a Tube?
Tonsil and adenoid surgery is common in young children, and breathing trouble around the anesthetic is what keeps many of us alert. A multicenter trial published in The BMJ on November 4, 2026 asked a practical question: in children 2 years to younger than 7 years having adenotonsillectomy, does a laryngeal mask airway lead to fewer respiratory events than a breathing tube? In experienced hands, the laryngeal mask looked better. I would not treat that as a blank check for every child or every room.
The study
Han and colleagues randomized 400 children (mean age 4.7 years) at four high volume tertiary hospitals in China. The children were ASA physical status I or II and scheduled for tonsillectomy, adenoidectomy, or both. The trial excluded a recent upper respiratory infection, a current asthma flare, severe obstructive sleep apnea, and a few other higher risk features. Each participating anesthesiologist had done at least 100 pediatric adenotonsillectomies with a laryngeal mask and 100 with a tube. The primary outcome was any perioperative respiratory adverse event from induction through discharge from the recovery room: laryngospasm, bronchospasm, desaturation, airway obstruction, severe cough, or stridor.
In the intention to treat analysis, at least one of those events occurred in 45 of 200 children (22.5%) managed with a laryngeal mask and 115 of 200 (57.5%) managed with a tube. That is an absolute difference of 35.0 percentage points (95% CI 25.7 to 43.5 percentage points fewer with the laryngeal mask; P<0.001). The gap was present during surgery (9.0% versus 17.5%) and afterward in recovery (16.5% versus 49.5%). Laryngospasm (0% versus 3.0%), desaturation (15.0% versus 28.0%), airway obstruction (3.5% versus 12.5%), and severe cough (10.5% versus 42.0%) were all less common with the laryngeal mask. Severe cough made up a large share of the composite. Three children needed conversion from a laryngeal mask to a tube because ventilation was inadequate after the mouth gag went in. No child in either group had a serious adverse event or needed another tube after the device came out. Rescue airway maneuvers after removal were also less frequent with the laryngeal mask (12.0% versus 37.0%).
How I read it
The size of the difference is hard to ignore, but the composite needs a close look. Severe cough counted as an event, and it was far more common after a tube. That is clinically real. Kids cough more when the trachea has been instrumented. It is not the same problem as laryngospasm or frank airway obstruction. Even so, the harder events moved in the same direction, and recovery teams did less rescue work after laryngeal mask removal.
I also keep the setting in mind. These were high volume pediatric ear, nose, and throat centers, and the anesthesiologists were very practiced with both techniques. Two of the four sites stopped enrolling early. The trial left out children with severe obstructive sleep apnea, who are a sizable share of the tonsillectomy list I see, and it did not include children younger than 2 years. People assessing events in the operating room and recovery could see which airway was used. That is hard to avoid, but it can color how events are called. Most children received midazolam beforehand, and sevoflurane was common for maintenance. Those details matter when I try to map the result onto a different hospital's routine.
What it means for practice here
In Casper we do not run four high volume pediatric ENT centers, but we do take care of children who need tonsils and adenoids out. This trial supports using a reinforced laryngeal mask for otherwise healthy kids in the 2 to 6 year range when the anesthesiologist and surgeon are comfortable with it, the mouth gag can be managed without losing the seal, and there is a clear plan to convert to a tube if ventilation fails. I would still reach for a tube when severe sleep apnea, concern about a shared airway, or less experience with this specific setup makes the laryngeal mask a poorer fit. The conversion rate here was low, 3 of 200, which is what you hope for with practiced teams. The lesson I take home is not that every child should get a laryngeal mask. It is that, in the right patient with the right team, avoiding a tube can spare a lot of coughing, desaturation, and extra hands in recovery.
Source
- Han Y, Yi X, Xia J, et al. Perioperative respiratory adverse events in children undergoing adenotonsillectomy with laryngeal mask airway versus endotracheal tube ventilation: multicentre, randomised controlled trial. BMJ. 2026;395:e101019. Published November 4, 2026. doi:10.1136/bmj-2026-101019. Full text (DOI)
This post is clinician commentary for educational discussion. It is not medical advice for any reader's personal care. Anesthesia and perioperative decisions should be made with the treating clinician based on the individual patient's circumstances.