Anesthesia for

OTORHINOLARYNGOLOGY

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Surgical procedures involving the eyes, ears, nose, and
throat require a cooperative relationship between the
surgeon and the anesthesiologist. It is important for the
anesthesiologist to appreciate the anatomy and physiology
of the structures in the operative field.

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 Shared airway
The problems of anesthetizing for surgical procedures in
and near the airway are common to ENT surgery

A patent, secure airway is essential for anesthetic practice

The tracheal tube and laryngeal mask airway should not
protrude into the surgical field

Access to the airway is lost once the patient is draped and

surgery started
If the airway is lost , surgery must be stopped and
appropriate adjustment made

Venous access is restricted and extension tubing on an

intravenous cannula is essential
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In addition, an understanding of the surgical procedure is
important.

Patients undergoing surgical procedures on the head, and

neck represent a diversity of age groups from infants to
the elderly.

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It is important to appreciate that manipulation of the
larynx, pharynx, and neck may precipitate cardiac
dysrhythmias and that blood loss can be underestimated
as a result of hidden losses within the surgical drapes
and blood swallowed into the stomach.

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The use of neuromonitoring techniques during surgery to
aid the surgeon in identification of peripheral nerves in
the operative area may influence the choice and dose of
anesthetic and neuromuscular blocking drugs.

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Damage to nerves that innervate the pharynx, larynx, and
especially the vocal cords (may be manifested promptly
after tracheal extubation) can occur during head and neck
surgery.

The presence of laryngeal and pharyngeal edema

should be considered before tracheal extubation.

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Special Considerations for Head and Neck Surgery

Most patients scheduled for head and neck surgery will

have their airway examined by the surgeon before
surgery.

The anesthesiologist should communicate with the

surgeon about the probability of a difficult airway and
whether nasal or oral tracheal intubation is indicated for
optimal surgical exposure.

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 Surgeons prefer a dry mouth , as it makes surgery easier
 An antcholinergic drug in the premedication also protects
against a bradicardia that often occurs during surgery
 An intravenous induction is used if there are no difficulties
with the airway
 Control of the airway is obtained with a nasotracheal tube,
and throat packs are inserted before surgery for collect
blood and debris
 It is easy to inadvertently leave the throat packs in at the
end of the surgery – obstruction of the airway occurs
 Complications during and after surgery are
common
 Severe hemorrhage is fortunately rare after dental
surgery , if there is any doubt about the adequacy
of homeostasis then the patient must be kept in
hospital under close observation
 Arrhythmias are common(30% of patients) and can
continue in the postoperative period
 Edema can be minimized by the use of steroids
before surgery
The anesthetic circuit is often lung (and occasionally
bulky) as the anesthetic machine is placed at the feet of
the patient

Two major problems may arise:

• The weight of the circuit can pull out or kink the
endoteracheal tube
• The surgeon may obstruct the tracheal tube when
operating
Extubation of the trachea can be undertaken under light or
deep anesthesia

Under deep anesthesia the patient is less likely to develop

laryngospasm, but is more likely to aspirate vomit, blood,
or debris

Under light anesthesia the patient has adequate protective

reflexes, is more prone to laryngospasm
An awake fiberoptic intubation of the trachea or a
tracheostomy under local anesthesia may be indicated if
difficult upper airway management is anticipated.

The anesthesiologist should be familiar with the variety

of endotracheal tubes that are available for head and neck
surgery to facilitate better surgical exposure

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 LARYNGOSPASM
Instrumentation or manipulation of the endolarynx or the
presence of blood or a foreign body can induce laryngospasm.

Laryngospasm is an exaggerated and prolonged response of

the protective glottic closure reflex, mediated by the superior
laryngeal nerve.

With severe Laryngospasm, the false cords and epiglottic body

come together firmly. Airflow is absent, there is no vocal sound,
and the true vocal cords cannot be seen.

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If laryngospasm persists, arterial hypoxemia and
hypercapnia will decrease postsynaptic action potentials
and brainstem output to the superior laryngeal nerve, and
the intensity of the laryngospasm will eventually decrease.

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The most common method of overcoming laryngospasm is
continued positive airway pressure applied by facemask or
the intravenous administration of a neuromuscular
blocking drug such as succinylcholine (0.25 to 1 mg/kg).

Intubation of the trachea may be warranted in selected

patients.

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 Tonsillectomy and Adenoidectomy

Patients who undergo tonsillectomy and adenoidectomy

are usually young and healthy. Although recurrent upper
respiratory tract infection remains a significant indication
for surgery, upper airway obstruction, especially during
sleep (obstructive sleep apnea [OSA]), accounts for an
increasing percentage of the procedures performed,
especially in children younger than 4 years.

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Preoperative evaluation for tonsillectomy or
adenoidectomy, or both, depends on the initial history and
physical examination.

In otherwise normal patients who have classic symptoms

of severe upper airway obstruction and adenotonsillar
hypertrophy, the preoperative evaluation rarely requires
any special studies.

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In some patients, if severe airway obstruction is
suspected, an electrocardiogram, echocardiogram, chest
radiograph, and coagulation studies may be considered.

Sedative premedication may be avoided in children with

OSA, intermittent upper airway obstruction, or very large
tonsils.

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 OBSTRUCTIVE SLEEP APNEA

OSA syndrome may be associated with behavior and growth

disturbances. Symptoms in these patients include snoring, sleep
disturbances and daytime hypersomnolence, decreased school
performance and personality changes, recurrent enuresis, hyponasal
speech, and growth disturbances.

Patients with OSA are often obese with potentially difficult upper
airway management.

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These individuals will probably have short, thick necks,
large tongues, and redundant pharyngeal tissues such that
upper airway obstruction is frequent and awake tracheal
intubation will be necessary.

Polysomnography to evaluate the severity of OSA requires

hospitalization, is expensive, and is rarely needed.

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 UPPER RESPIRATORY TRACT INFECTIONS
Patients may arrive at the hospital for elective tonsillectomy
and adenoidectomy with an acute upper respiratory tract
infection. Surgery for these patients is usually postponed
until resolution of the upper respiratory tract infection,
which is typically 7 to 14 days.

Laryngospasm with airway manipulation may be more likely

to occur in the presence of an upper respiratory tract
infection.

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 GASTROESOPHAGEAL REFLUX DISEASE
Gastroesophageal reflux disease (GERD) may be a
significant symptom in children with chronic lung disease
or upper airway obstruction (or both) secondary to
increased intrathoracic negative pressure.

This is particularly relevant in neurologically abnormal

patients (hypotonia, developmental delay) because such
patients have a high incidence of GERD even without
upper airway obstruction.

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GERD is a consideration in young children with
significant developmental delay who require tonsillectomy
to treat upper airway obstruction.

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 MANAGEMENT OF ANESTHESIA

Management of anesthesia for patients undergoing

tonsillectomy is focused on airway considerations and
bleeding.

Continuous positive airway pressure during

induction of anesthesia may be useful for alleviating
upper airway obstruction.

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Placement of a cuffed endotracheal tube will decrease the
incidence of aspiration of blood. As with an uncuffed tube,
a cuffed endotracheal tube should be appropriately sized
to allow an air leak around the tube with 20 to 25 cm H20
of peak airway pressure.

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The tracheal tube cuff is inflated beyond this point only if
high peak airway pressure is needed to ventilate the lungs
adequately or if hemorrhage suddenly develops.

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When difficult tracheal intubation is anticipated, it may be
helpful to have an otolaryngologist present.

The use of an oral RAE tube for tracheal intubation may

optimize visualization of the surgical field.

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The supraglottic area may be packed with petroleum
gauze to minimize the likelihood of inhalation of blood from
the pharynx.

When gauze packing is used, it is important to maintain

an appropriate leak around the tube during the application
of positive airway pressure.

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The practice of monitoring young children for 24 hours
after surgery is based on observations of postoperative
airway obstruction occurring in children younger than 4
years as late as 18 to 24 hours postoperatively.

In addition to young age, risk factors associated with

postoperative airway obstruction after tonsillectomy may
include prematurity and recent upper respiratory infection.

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Surgeons are meticulous about ensuring a dry tonsillar
bed at the end of surgery and often place a pack in the
posterior of the pharynx to limit draining of blood into the
stomach during the procedure. Inserting an orogastric
tube into the stomach before extubating the trachea while
being careful to not traumatize the adenoidectomy site is
a frequent maneuver to remove any blood that may have
drained into the stomach.

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Tracheal extubation is performed when the child is awake
and responding. In patients with reactive airway disease,
including asthma, tracheal extubation may be performed
while the patient is still anesthetized to decrease the
likelihood of bronchospasm and laryngospasm.

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 POSTOPERATIVE CARE AND COMPLICATIONS

Dexamethasone administered intravenously may be

useful for decreasing postoperative pain. Adding an
intraoperative dose of an antiemetic and removing blood
from the stomach may combine to decrease postoperative
emesis.

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Hemorrhage from a bleeding tonsil in the postoperative
period is a recognized complication. The need for tracheal
reintubation may be complicated by the presence of large
amounts of swallowed blood in the stomach. In this regard,
care should be taken to not oversedate these patients. If
the bleeding is not controlled, the patient should be
returned to the operating room for exploration and
surgical hemostasis.

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Acute airway obstruction such as laryngospasm can lead
to negative-pressure pulmonary edema. This occurs as
the patient breathes against a closed glottis and negative
intrathoracic pressure is created. This pressure is
transmitted to interstitial tissue, where the hydrostatic
pressure gradient is increased and enhances fluid
movement out of the pulmonary circulation into the alveoli.

Airway obstruction in the postoperative period can also be

associated with retention of a pharyngeal pack.

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 Postoperative Complications of
Tonsillectomy
• Emesis (occurs in 30%–65% of patients; mechanism unknown but
may include the presence of irritant blood in the stomach)
• Dehydration
• Hemorrhage (75% occurs in first 6 hours after surgery; if surgical
hemostasis is required, a full stomach and hypovolemia should be
considered)
• Pain (minimal after adenoidectomy and severe after tonsillectomy)
• Post obstructive pulmonary edema (rare but possible if the patient
has had a prior acute upper airway obstruction; treatment may
include supplemental oxygen and administration of diuretics)

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Examples of patients in whom early discharge is not
advised after tonsillectomy include those younger than 3
years of age and those with abnormal coagulation values,
evidence of obstructive sleep disorder or apnea, presence
of a peritonsillar abscess, and conditions (distance,
weather, social conditions) that would prevent close
.observation or prompt return to the hospital

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 Laser Surgery
Laser surgery provides precision in targeting airway
lesions, minimal bleeding and edema, preservation of
surrounding structures, and rapid healing. The carbon
dioxide laser has particular application in the treatment of
laryngeal or vocal cord papillomas, laryngeal webs,
resection of redundant subglottic tissue, and coagulation
of hemangiomas.

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In most cases laser surgery is preceded by microdirect
laryngoscopy. The use of small-diameter endotracheal
tubes (5.0 or 5.5 mm internal diameter) is necessary for
optimum exposure. Brief skeletal muscle paralysis as
provided by an infusion of succinylcholine may be useful.

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 MANAGEMENT OF ANESTHESIA

Anesthesia during laser surgery may be administered with

or without an endotracheal tube. However, appropriate
laser-resistant endotracheal tubes should be available. In
this regard, all polyvinyl chloride endotracheal tubes are
flammable and can ignite and vaporize when in contact
with the laser beam.

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Some surgeons may prefer using a Dedo or Marshall laryngoscope
and intermittent ventilation with a Sanders jet ventilator.

The Sanders jet ventilator delivers oxygen at 50 psi directly through a

port in the laryngoscope.

If a Dedo or Marshall laryngoscope is used, maintenance anesthesia

can be accomplished with an intravenous anesthetic.

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Use of the Sanders jet ventilator is associated with a risk
for pneumothorax and pneumomediastinum as a result of
rupture of alveolar blebs or a bronchus.

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Laser surgery produces a plume of smoke and particles (mean
size, 0.31µm) that can be deposited in the alveoli if aspirated .
This hazard can be minimized if an efficient smoke evacuator
and special masks are used. A misdirected laser bean can also
lead to perforation of a viscus and transection of blood vessels.

Other risks include venous gas embolism and ocular

injury.

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Hazards Associated with Laser Surgery

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The patient's eyes must be protected by taping them shut,
followed by the application of wet gauze pads and a metal
shield to prevent laser penetration.

All operating room personnel should wear special

protective glasses.

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 Characteristic signs and symptoms of acute epiglottitis
include
(1) A sudden onset of fever, dysphagia, drooling, thick
muffled voice, and preference for the sitting position
with the head extended and leaning forward
(2) Retractions, labored breathing, and cyanosis when
respiratory obstruction is present.

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 Emergency anesthesia
 Emergency anesthesia should not be underestimated
 The principle problem in patients with a abscess or
mandibular fractures is difficulty in opening the mouth
and henes the difficulty with intubation
 Distorted facial anatomy compounds the problem
 Fiber optic laryngoscopy and intubation , or an
inhalation induction followed by blind nasal intubation ,
is often necessary in these patients
• Muscle relaxation must not be given until patency and
control of the airway is secured
• The urgency of the surgery should be discussed with
the surgeon
• Only rarely is it a life threatening emergency
• If the airway is not safe postoperatively , the patient
should be managed in an Intensive Care Unite
DELIBERATE HYPOTENSION/
PERMISSIVE HYPOTENSION

Ear, Nose, Throat/Oral Surgery

 DELIBERATE HYPOTENSION
:DEFINITION
Reduction of the systolic blood 
pressure to 80-90mmHg
Reduction of mean arterial 
pressure (MAP) to 50-65 mmHg
reduction of baseline MAP 30% 
DRUG. 2007; 67 (7): 1053-76
Safe level of DH
• Depends on the pt.
• Healthy young pt. tolerate mean B.P. as
low as 50-60 mmHg.
• Ch. hypertensive pts. tolerate a mean of
B.P. no more than 25% lower than the
base line.
• Pts. with TIA may not tolerate any
decrease in cerebral perfusion pressure.
 Method
• Physiologic technique

• Pharmacologic technique
 Physiologic technique

• Body positioning
• Hemodynamic effects of mechanical
ventilation
• Changes in heart rate & circulatory
volume
 Pharmacologic technique
Ideal agent
 Ease of administration
 Predictable & dose-dependent effect
 Rapid onset/offset
 Quick elimination without the production of
toxic metabolites
 Minimal effects on blood flow to vital organs
Inhalational anesthetics
– negative inotropic effect
vasodilation

Advantage Disadvantage
 Provides surgical

anesthesia  Decreases CO
 Rapid onset/offset  Cerebral

 Easy to titrate vasodilation

 Cerebral

protection
 Anesthesia Technique
• Monitoring
• Induction
• Position head up 450
• BP drop range 20% - 40% of baseline
• HR range 50 – 60 beat/min
 Observation, cont’d
 PONV:
◦ Nausea & Vomiting.
◦ prophylactic anti-emetics are given peri-
operatively.
 …DH
 Ear Sx.
• Produce bloodless surgical field for microscopy
• Stapedectomy :
• <0.75ml of blood loss good op. condition
• >1.5ml of blood loss bad op. condition

• In middle ear Sx. Even slight hemorrhage

fibrosis so B.P. Improves the results.
 Deliberate Hypotension In
FESS
 Moderate DH (systolic pressure 80

80mmHg)
Reduces the capillary bleeding

 Bloodless operative field provides good

sinuses surgical conditions

THANK YOU
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