tips in anesthesia in otolaryngology

1. Tips in Otolaryngology Anesthesia
DR HOSAM M ATEF; MD
SEUZ CANAL UNIVERSITY 2/24/20161

2. The never ending challenges shared airway
‫فيه‬ ‫رجال‬ ‫مثال‬ ‫هللا‬ ‫ضرب‬
‫ورجال‬ ‫متشاكسون‬ ‫شركاء‬
‫مثال‬ ‫يستويان‬ ‫هل‬ ‫لرجل‬ ‫سلما‬
‫يعلمو‬ ‫ال‬ ‫أكثرهم‬ ‫بل‬ ‫هلل‬ ‫الحمد‬‫ن‬
2/24/20162

5. LMA Classic

6. Intubating LMA(LMA Fastrach)
Body
weight
ILMA
size
Air
volume
30-50kg 3 20ml
50-70kg 4 30ml
70-100kg 5 40ml

7. LMA ProSeal

8. LMA Supreme

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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.

19. 2/24/201619
 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
 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.

23. 2/24/201623
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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 An awake fiberoptic intubation of the trachea or
a tracheostomy under local anesthesia may be
indicated if difficult upper airway management
is anticipated.
 Be aware 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.

27. 2/24/201627
• “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.

29. 2/24/201629
 The most common method of overcoming
laryngospasm is continued positive airway pressure
applied by facemask
 Intravenous administration of a neuromuscular
blocking drug such as succinylcholine (0.25 to 1
mg/kg). Intubation of the trachca may be warranted
in selected patients.

30. 2/24/201630
Tonsillectomy and Adenoidectomy
 Patients who undergo tonsillectomy and
adenoidectomy are usually young and healthy.
 Recurrent upper respiratory tract infection remains
a significant indication for surgery
 Upper airway obstruction especially during sleep
(obstructive sleep apnea [OSA]),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.
 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 include snoring, sleep disturbances
and daytime hypersomnolence, decreased
school performance and personality changes,
recurrent enuresis, hyponasal speech, and
growth disturbances.

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 Patients with OSA are often obese
 Difficult upper airway management
 Short, thick necks, large tongues, and redundant
pharyngeal tissues such that upper airway
obstruction

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 Frequent (UAO) and awake tracheal intubation will
be necessary.
 Polysomnography to evaluate the severity of OSA
requires hospitalization, is expensive, and is rarely
needed.

37. polysomnography
2/24/201637

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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 →→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
significant symptom in children with chronic lung
disease or upper airway obstruction (or both)
secondary to increased intrathoracic negative
pressure.
 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.

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 In addition to young age, risk factors ssociated
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
 Pack in the posterior of the pharynx to limit
draining of blood into the stomach during the
procedure.
• .

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 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
 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.

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 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.

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 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)

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 Pain (minimal after adenoidectomy and severe
after tonsillectomy)
 Postobstructive 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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Early discharge
 Examples of patients in whom early discharge
is not advised after tonsillectomy include
 Younger than 3 years of age
 Abnormal coagulation values
 Evidence of obstructive sleep disorder or apnea

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 Presence of a peritonsillar abscess
 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.

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 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 micro
direct 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.

64. 2/24/201664
 Some surgeons may prefer using 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 Marshall laryngoscope is used, maintenance
anesthesia can be accomplished with an
intravenous anesthetic.

65. 2/24/201665
 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
then 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.

71. Suggestions for drawer labels
Plan A
Initial intubation strategy
OptimiseBougie Alternative
positionlaryngoscope
Remember to move
on if not making
progress
Plan C
Maintain oxygenation
Facemask LMA device
+/- airway adjunct
Postpone surgery
Awaken patient
Plan B
Secondary intubation strategy
LMA deviceFibreoptic intubation
Remember to move
on if not making
progress
Plan D
Can’t intubate, can’t ventilate
Cannula
cricothyroidotomy
Remember to move
on if not making
progress
Plan D
Can’t intubate, can’t ventilate
Surgical
cricothyroidotomy
Remember to move
on if not making
progress