Down’s syndrome is a congenital anomaly occurring due to extra chromosome attached to Chromosome 21. Cardiovascular, respiratory and central nervous system, atlanto-axial joint instability may be involved in Down’s syndrome as an isolated system involvement or multiple system involvement, thus posing several anaesthetic challenges. Pediatric tonsillectomy and adenoidectomy (TNA) is a common and usually uncomplicated surgery. These surgical procedure involves manipulation of neck for proper surgical field accessibility. Since Downs syndrome patients may have atlanto-axial joint instability, manipulation of the neck for intubation and surgery should be performed very cautiously. We report 7 year old male child, a case of Downs syndrome posted for tonsillectomy surgery. We discussed the peri-operative management of this patient.