Anesthesia For ENT Surgeries

Anesthesia For ENT
Anesthesia For Ear, Nose and Throat Surgeries
Common surgeriesExternal ear
• Removal of simple lesions
• Foreign bodies in ext.auditory canal
• Preauricular abnormalities
• Exostoses
Anesthesia For Ear, Nose and Throat Surgeries
Middle ear , Mastoid and throat:
• Adenoidectomy
• Tonsillectomy
• Otitis media
• Mastoidectomy
• Tympanoplasty
• Myringoplasty
Anesthesia For Ear, Nose and Throat Surgeries
Inner ear
• Cochlear transplant surgery
• Endolymphatic sac decompression
• Labyrinthectomy
Type of Anesthesia
General Anesthesia
• A through preoperative assessment advised.
• Specific attention paid to hypertension or any
cardiovascular disease which limits attempts to
intraoperative control BP.
• No specific premedication required
• Beta blocker or clonidine if required can be given iv
with intraoperative monitoring.
 History and investigations:
• Detailed history and examination (especially airway
assessment and relevant pathology).
• Assessment of comorbidities, previous anesthetic
• Smoking and alcohol consumption.
• Screening for obstructive sleep apnea.
 History and investigations :
• Relevant and targeted investigations.
• Preoperative endoscopic airway examination.
• Review of airway imaging: CT, MRI scans.
• Preop. optimization if possible, e.g. nutritional
status, respiratory system.
 Premedication:
• Avoid sedative medication if there is any
suggestion of airway compromise.
• Consider gastric acid prophylaxis.
 Airway equipment
• Laryngoscopes with a variety of blades
• Video laryngoscopes, fibreoptic scopes, optical stylets (Bonfils).
• Variety of ET tubes standard, preformed, reinforced, laser tubes.
• Supraglottic airway devices.
• Bougies, stylets, exchange catheters and other airway adjuncts.
• Jet ventilation equipment.
 Airway equipment
• Jet ventilation equipment.
• Cricothryroidotomy/tracheostomy equipment.
• Equipment for topical application of LA for airway.
• Difficult airway trolley.
 Establish IV access
 Monitoring:
• Standard monitoring
• Neuromuscular monitoring
• Core temperature
• Invasive monitoring may be required depending on comorbities, injuries; extent, complexity and duration of
 Preoxygenation
• Face mask
• Nasal oxygenation during efforts securing a
• THRIVE (Transnasal Humidified RapidInsufflation Ventilatory Exchange)
Transnasal Humidified Rapid-Insufflation Ventilatory Exchange
o Mechanisms of action
• Warmth & humidification allows higher flows
• Flush dead space in nasopharynx decreases CO2
• Warmed, humidified – less constriction, more
• Distending pressure
• Apneic oxygenation
 Induction:
• IV or inhalational induction or awake intubation
• Titrate to patient response; rapid sequence if warranted
• Rocuronium is a good choice, with neostigmine available to
reverse if required
• Sevoflurane or desflurane
• Remifentanil, alfentanil, fentanyl
• Steroids for swelling and antiemesis
• Antibiotics
 A throat pack is used to prevent blood and debris
contaminating the airway or being swallowed.
 Throat packs are often inserted to:
• Absorb material created by surgery in the mouth
• Prevent fluids or material from entering the oesophagus
or lungs
• Prevent escape of gases from around tracheal tubes
• To stabilize artificial airways
 If a throat pack is retained after surgery it can lead to obstruction of the airway
and result in significant morbidity or mortality.
 The National Patient Safety Agency (NPSA) recommends:
1• Label or mark patient either on the head or, exceptionally, on another visible
part of the body with an adherent sticker or marker.
2• Label artificial airway (e.g. tracheal tube or supraglottic airway).
3• Attach pack securely to the artificial airway.
4• Leave part of pack protruding.
5• Formalized and recorded ‘two-person’ check of insertion and removal of
• Oxygen and air with inhalational agent or TIVA.
• Remifentanil infusion.
• Head-up position and relative hypotension can
reduce bleeding and aid surgical field. Careful neck
extension to improve access to neck and glottis.
 Throat pack must be removed and confirmed by team
members at sign out.
 Airway clear of secretions and blood.
 Assessment of airway edema: presence of leak around
tube when cuff is down is suggestive that airway is not
overly edematous.
 Plan for extubation using the DAS guidelines.
• Depending on patient and surgery, return to day case
facility, head and neck ward, HDU or ICU.
• Analgesia is not a particular problem: use a multimodal
approach with LA, paracetamol, NSAIDs and opiates.
• Antiemetics.
• Important complications relate to airway compromise. A
level of high vigilance must be maintained by all staff.
Anesthesia For
And Adenoidectomy
• A day case surgery (adult or children)
• Adenotonsillar hypertrophy can present with nasal obstruction,
recurrent infections, secretory otitis media, deafness
(secondary to Eustachian tube dysfunction), and obstructive
sleep apnea (OSA) [not a day case].
• Adenoidectomy and/or tonsillectomy procedures are
performed through the mouth. A Boyle– Davis gag is used for
tonsillectomy. Difficulties may be encountered because of
poorly placed gag, obstructing the tracheal tube or laryngeal
mask airway.
 Chronic/recurrent throat infections.
 Comorbidities
• Obstructive sleep apnoea
• Congenital abnormalities, e.g. Down syndrome.
• Older adults for tonsillectomy
• May have malignancy.
• Other incidental medical conditions.
• Cor pulmonale due to long-term hypoxia.
 Detailed assessment and appropriate investigations
 Assess for OSA
• STOP-BANG questionnaire
• Epworth sleep score
• Bleeding history is important.
• Detailed airway assessment (LEMON).
• Possible difficult management due to large tonsils.
• Anxiolytic if essential but avoid if a history of airway
obstruction or OSA.
• Standard monitoring.
• Intravenous or inhalational induction.
• Airway:
 Intubate with a preformed oral or reinforced tube.
 Reinforced laryngeal mask
• Oral tubes must be carefully secured in the midline in order
to lie correctly in the Boyle– Davis gag.
• Patients are positioned with the neck extended.
• Instrumentation of the postnasal space during
adenoidectomy may induce a bradycardia requiring
treatment with atropine or glycopyrrolate.
 Analgesia
• Opioid analgesia is usually required.
• IV paracetamol.
• NSAIDs unless contraindicated.
• Infiltration of local anaesthetic into the tonsillar bed.
 Careful suctioning of the pharynx under direct vision.
 Extubation either deep or awake
• NSAIDs have not been found to significantly increase bleeding in
tonsillectomy patients.
• Maintain IV access in case of early postoperative bleeding.
• Bleeding may not be detected in children until vomiting occurs.
• Severe OSA patients have a higher incidence of perioperative
complications and may need postoperative HDU/ICU care.
• Routine use of antiemetic drugs to prevent PONV is
Anesthesia For
Two types of esophagoscopy are possible: rigid and flexible
fiberoptic. Rigid esophagoscopy necessitates general
anesthesia, whereas flexible is well tolerated with topical
anesthesia ± sedation in adults.
• Removal of foreign body/food bolus
• Investigation of carcinoma, e.g. as part of panendoscopy
• Dilatation of strictures
• Assessment and treatment of oesophageal/ pharyngeal
• Endoscopic treatment of pharyngeal pouch
• Obstruction poses an aspiration risk with food and saliva
present above the level of obstruction.
• Chronic obstruction may result in weight loss, dehydration
and silent aspiration.
• Pre-existing comorbidities, e.g. cardiovascular disease,
GORD, neurological conditions (dysphagia may be a
presenting symptom).
• Investigate according to underlying cause.
• Treat dehydration or chest infection.
• Avoid sedating premedication.
• Measures to neutralize gastric acid take time to be effective;
there will still be a danger from blood, food and secretions
above the level of obstruction.
• Shared airway with ENT surgeons so ensure good
• Rapid sequence induction and endotracheal intubation is
mandatory (with a tube smaller than usual) due to risk of
regurgitation. Avoid hand ventilation if possible to prevent
further impaction of foreign bodies.
• Secure tube to the left to allow for the esophagoscope – the
tube can become kinked; consider a reinforced tube and pay
close attention to airway pressures.
• IV induction and short-acting muscle relaxant are required.
• Desflurane allows prompt return of airway reflexes.
• Use neuromuscular monitoring and reverse if necessary.
• Cardiovascular disturbance should be expected. In the
presence of dehydration or cachexia, hypotension may occur.
Hypertension and tachycardia are common and should be
dealt with promptly, particularly in the elderly or those with
cardiovascular disease. Fentanyl or alfentanyl can attenuate
this response.
• Patients remain an aspiration risk; therefore, extubate awake
and fully reversed reflexes.
• Odynophagia (pain when swallowing) may indicate
esophageal perforation and can lead to pneumomediastinum,
mediastinitis, pneumothorax and surgical emphysema. If there
is suspicion of this, a chest X-ray and prompt discussion with
the surgeons are necessary.
• Ensure IV fluids are prescribed if the patient is to remain nil
by mouth postoperatively.
Anesthesia For
Middle Ear
Surgery to the external and middle ear structures tends to be elective for
improvement of patient quality of life whether through restoration of
hearing, decrement of infection or improvement of cosmetic defects.
Careful dissection of small structures is involved such as ossicles, using
an operating microscope. The surgical field must be as free of blood as
possible. A small amount of blood can obscure the surgeon’s view
through the microscope. Injury to the facial nerve is possible with an
incidence of 0.5%–3.5%.
• Detailed assessment and investigations specific for the individual
• Premedication is required.
• Standard minimum monitoring.
• Neuromuscular monitoring.
• Invasive blood pressure monitoring if hypotensive anesthesia is
requested in certain patients.
• Head and neck will be rotated to the opposite side from the
operative field. Avoid hyperextension of the neck to minimise
chance of brachial plexus injury.
• Extreme lateral head movement can be avoided by using
lateral tilt of the operating table.
• The dependent ear and eye should be free of excessive
pressure especially in long cases, with use of a head ring.
• Head-up tilt of 10–15° helps to minimize bleeding.
• Endotracheal tube is commonly used.
• Laryngeal mask may suffice but careful seating and seal
must be confirmed with the head turned to the operative site.
• Long anesthesia circuit tubing is required.
• Recheck all connections and that gas exchange and
ventilation are optimal in the final surgical position prior to
• TIVA using propofol.
• Inhalational agent.
• Remifentanil.
• Protect eyes.
• Bleeding must be minimised. The severity of bleeding is related
as much to venous as to arterial blood pressure.
• A clear airway is essential. A partially obstructed airway impedes
expiration, increases CO2 levels and raises venous pressure. An
armored endotracheal tube avoids kinking.
• Anesthesia should be smooth. Avoid straining and coughing
as they increase venous pressure and bleeding.
• Avoid tachycardia. Beta-blockers are useful – small doses of
labetalol, esmolol or metoprolol can be titrated intravenously.
• Induced hypotension may be requested. Profound
hypotension is unnecessary and may be harmful.
• Intubate with small amount of relaxant and allow to wear off
or reverse.
• Use nerve stimulator to monitor block.
• Alternatively intubate with opiates and LA spray to cords.
• Use a laryngeal mask.
The use of N2O is controversial. Its accumulation in the closed
middle ear space is problematic especially in the presence of
eustachian tube blockage. This results in an increase in
middle ear pressure. During tympanoplasty, the tympanic
membrane graft may become dislodged. It also increases
PONV. If tympanoplasty, stapedotomy or stapedectomy is
planned, N2O should be avoided.
• The ear is bandaged at the end of the procedure. To
prevent displacement of the tracheal tube and trauma to the
eyes, the anesthetist should supervise this.
• Nausea, vomiting and dizziness can be a particular problem
following these procedures. Antiemetics should be given
using a multimodal approach and not a single agent. Pain is
not usually severe.
Anesthesia For
Operations On The
These can be simple and straightforward, e.g. manipulation of nasal bones;
or they may be more complex and prolonged, e.g. transnasal skull base
Septoplasty is performed to relieve symptoms of nasal obstruction or as a
component of rhinoplasty. It can be combined with turbinate reduction
surgery, or to facilitated CPAP in OSA patients. Rhinoplasty is performed for
cosmetic or reconstructive surgery, post-trauma, reconstruction after tumor
resection or to improve nasal breathing.
A bloodless field is helpful and the aim is for a still patient with no or minimal
coughing and straining followed by a smooth emergence. Some operations
such as septoplasty may be performed under local anesthesia with sedation
in cooperative patients although most nasal operations require a general
• Submucus resection of septum, septoplasty, turbinectomy, polypectomy,
antral washout, rhinectomy.
• Detailed history and examination with appropriate
• Patients with polyps often have a history of atopy or the triad
of asthma, polyps and aspirin sensitivity.
• Postnasal drip and recurrent chest infections are common.
• Treat chest infections and optimize chronic medical
• Patient with nasal fractures may have sustained other
injuries or swallowed a significant amount of blood.
• Correct any hypovolemia in patients who have bled
• There is an increasing incidence of patients with obstructive
sleep apnea.
• Anxiolytic premedication if required.
Vasoconstrictors will reduce bleeding from nasal surgery and can be
administered as a spray, paste, infiltration or on soaked swabs:
• Moffatt’s solution (2 mL 8% cocaine, 2 mL 1% sodium bicarbonate
and 1 mL 1:1000 epinephrine).
• Modified Moffatt’s solution (10% cocaine and 8.4% bicarbonate).
• Local anesthetic with 1:100,000–1:200,000 epinephrine.
• Lidocaine 5% and phenylephrine 0.5% spray.
• Xylometazoline (A nasal vasoconstricting decongestant drug)spray.
• Cocaine 4%–10% (recommended maximum dose 1.5 mg/kg).
• Routine monitoring.
• A rapid sequence induction is required as patients may have
swallowed a significant amount of blood.
• Induction agent of anesthetist’s choice.
• Oral preformed or reinforced tracheal tube. Some use a laryngeal
• A throat pack is inserted, if required.
• Protect eyes with ointment but not covered in order that the
surgeon can check for orbital perforation or damage to the optic
• Inhalational agent and opiates (e.g. Remifentanil infusion)
• Muscle relaxant as necessary.
• Head-up position with the thighs flexed at the hip in order to
improve venous return.
• When the procedure is complete, perform pharyngoscopy to
ensure that the pack has been removed completely and any
remaining blood clots or debris are aspirated.
• Extubate awake sitting up.
• Encourage the patient to breathe through his or her mouth because
nasal packs are often in place.
• Plasters and bolsters applied to the nose may make the application of a
facemask difficult.
• Administer oxygen in recovery in a routine fashion but CPAP is required
as soon as possible in OSA patients.
• Leave the intravenous cannula in situ in case of bleeding.
• Repacking may be necessary should bleeding from the nose continue.
• Regular paracetamol and NSAIDs are usually adequate. Opioids are
needed following more extensive surgery but be aware of respiratory
depression in OSA patients. Prescribe an antiemetic.
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