Dr. D. SUVANKAR discusses anesthesia considerations for various ENT endoscopic procedures including bronchoscopy, microlaryngoscopy, and esophagoscopy. Key points include: 1. Rigid bronchoscopy allows direct visualization of the airway but requires ventilation, while flexible bronchoscopy can be done with minimal sedation. 2. Microlaryngoscopy provides magnified visualization of the larynx and allows for precision procedures like laser surgery. 3. Esophagoscopy is commonly used to remove foreign bodies from the esophagus in ENT and requires general anesthesia in children to prevent aspiration if the object dislodges.

1. Dr.D.SUVANKAR
ANAESTHESIA IN ENT SCOPIES

2.  Bronchoscopy
 Microlaryngoscopy
 Esophagoscopy

3. Bronchoscopy
 Bronchoscopy is an endoscopic technique to
visualise the inside of the airways for diagnostic
and therapeutic purposes.

4. History
 Killian- First Rigid bronchoscopy
(1898)
-Father of bronchoscopy
 Algernon Coolidge- First successful
removal of tracheal foregion body
 Jackson- Lighted Bronchoscope
 Szigeti Ikeda-fibreoptic bronchoscope
(1967)

5. Types
1.Rigid Bronchoscopy
2.Felxible bronchoscopy

7. Indications for Rigid Bronchoscopy
 Malignant or benign tumours
 Foreign bodies
 Palliative obstruction relief of the main
airway
 Iatrogenic stenosis
 Extrinsic compression
 Intra-luminal tracheo-bronchial repair of
sealing defects
 Biopsies and cryotherapy

8. Contraindications
 Uncontrolled coagulopathy
 Extreme ventilation and oxygenation
demands
 Tracheal obstruction

9. Challenges in Bronchoscopy
 Shared area of interest
 Instrumentation of airway
 Ventilation
 Inadequate starvation
 Depth of Anaesthesia
 Arrythmias

10. Foreign Body in AIRWAY
 Where ??
 What ?
 When ??
 Starvation?

11. Goals of anaesthesia in Bronchoscopy
 Maintenance of adequate ventilation
and oxygenation
 Adequate depth of anesthesia,
amnesia, analgesia
 Prevention of pulmonary aspiration
 Quick return of consciousness,
respiratory drive and upper airway
reflexes
 Minimization of secretions.

12. Preoperative evaluation
 Routine investigations
 Coagulation profile
 ABG
 PFT
 CT SCAN

13. Intra operative monitoring
 Pulse oximetry
 ECG
 NIBP
 ABG

14. Premedication
 Antisialogogues –Atropine
Glycopyrrolete
 Antiemetics-Ondensetron
Metoclopramide
 Benzodiazepines – Midazolam
 Opioids
 Bronchodilators

15. VENTILATION STRATEGIES IN
BRONCHOSCOPY
 Apnoeic oxygenation
 Spontaneous assisted ventilation
 Controlled ventilation
 Manual jet ventilation
 High frequency jet ventilation.

17. 1.Apnoeic ventilation
 Preoxygenation
 Patient is hyperventilated to achieve profound
hypocapnia
 Fine catheter is passed through trachea &
oxygen insufflated at 15-20 liters/min through
out the procedure
 TIVA & Muscle relaxant
 Rise in arterial co2 tension
 Not suitable for prolonged bronchoscopy
 Not more the 10 minutes procedure
 Works well in patients without significant
pulmonary disease

18. 2.Spontaneous assisted ventilation
 TIVA
 Supplemental oxygen is given via rigid
bronchoscope and the ventilation is
assisted.
 Bronchoscope is introduced and the
patient is ventilated with high flow
oxygen manually.
 Muscle relaxants are not used
 Anaesthesia is maintained with repeated
injections/infusion of intravenous drugs
and ventilation assisted in case of
apnoea or desaturation.

19. 3.Jet ventilation
 This method is based on Bernoulli’s
principle High pressure gas source
that is applied to the open airway in
small bursts via a small catheter.
 Two techniques of jet ventilation
A)Manual jet ventilation
B)Automated jet ventilation

20. A)Manual jet ventilation
Hand operated valve
which is connected to
100% oxygen and the
pressure is delivered at
50psi or less .
A jet frequency of 8-10/min is sufficient to allow
time for exhalation and prevents air trapping
and
barotrauma

21.  Airway pressure monitoring
 I:E Ratio -1:4
 Monitoring tidal volume is difficult
 Periodic CO2 and blood gas measurement
or transcutaneous capnography may be
used to assess ventilation.

22. B)Automated jet ventilation
 Higher respiratory rates 60-300/ min.
 The operator controls the applied
pressure, respiratory rate and inspiratory
time to maintain adequate oxygenation.
 High respiratory rate and low VT gives a
‘quiet’ procedure field
 Advantage-can be used in patients with
bronchopleural,bronchoesophageal and
bronchomediastinal fistula which
requires low airway pressures.

23. 4)Controlled ventilation
 The bronchoscope is used like an
endotracheal tube for positive pressure
ventilation.
 Other ports are closed of rigid scope and
packing of the oropharynx is done to
minimize the leak
 Manual bag ventilation
 Limitations-
operator judgement
lack of control of FiO2with high flow
rate and inappropriate delivery of

24.  TIVA
 Opiods-to suppress airway reflexes and
blunt adrenergic responses to pain
 Propofol or thoipentone can be used ,after
induction propofol infusion of 100-200
ug/kg /min can be used to maintain depth
of anaesthesia
 Muscle relaxants

25. Flexible Bronchoscopy

26. Anaesthesia for flexible bronchoscopy
 Antisialogogues
 Minimal sedation with benzodiaepines
and opioids
 Dexmedetomidine
 Topical anaesthesia
 Blocks-Glossopharyngeal Block
-Superior laryngeal nerve Block
-Translaryngeal Block

27. Indications for flexible bronchoscopy
 Aspiration of retained secretions
 Bronchopulmonary lavage
 Placement of endotracheal tube in a
difficult situation
 Laser resection of tumour
 Placement of airway stent
 Removal of foreign body
 Evaluation of airway

28. Contraindications-
Absolute-
 Inability to maintain adequate oxygenation
 Operator inexperience
 Relative-
 Profound refractory hypoxemia
 Severe bleeding diathesis uncorrectable
prior to the procedure

29. Anaesthesia for flexible bronchoscopy
 Antisialogogues
 Minimal sedation with benzodiaepines
and opioids
 Dexmedetomidine
 Topical anaesthesia
 Blocks-Glossopharyngeal Block
-Superior laryngeal nerve Block
-Translaryngeal Block

30. Rigid bronchoscopy Flexible bronchoscopy
Pros •Compromised airway
patency
•Can be done bedside
•Topical anaesthesia
•Better visualistion
•Sponataneous ventilation
•Done in upright position
Cons •Done in operating room
•Requires ventilation
•Teeth may be damaged
•Limited visualisation
•Bleeeding
•Perforation
•Risk of laryngeal oedema,
bleeding and pneumothorax
•Needs fragmentation of foreign
body before removal
•Small size of aspiration
channel

31. Complications of bronchoscopy
 Oral trauma
 Bleeding
 Dysrrythmias
 Hypoxia
 Perforation of airway

32. Microlaryngoscopy
 Larynx is visualised through microscope
 Allows magnified vision of larynx
 Indications
 A)Diagnostic
1.Hoarseness of voice cannot be
diagnosed on direct or indirect
laryngoscopy
2.Biopsy of laryngeal lesion
3.assesment of laryngeal trauma

33.  B)Therapeutic
1.Removal of foreign bodies
2.laser cordectomy in ca vocal cord
3.Dilatation of subglottic stenosis
4.Arytenoidectomy in cases of
abductor cord palsy
5.Excision of vocal cord cysts ,nodules
and haemangiomas

34. Advantages over direct laryngoscopy
 Magnified binocular vision
 Both hands of operating surgeon are
free
 Exact precision achieved when
performing laser or crayosurgery
 Video attachment

35.  Microlaryngeal tracheal surgery(MLT)
tubes-
Smaller external diameter
Large high volume low pressure cuff

36. Esophagoscopy
 Esophagoscopy is a procedure in
which a flexible or rigid endoscope is
inserted through the mouth or, more
rarely, through the nares and into the
esophagus

37. Indications
 Foreign body or food bolus
impaction
 Evaluation of GERD
 Screening of barrets esophagus
 Treatment of varices
 Evaluation and management of
dysphagia
 Biopsy of lesion
 Dilatation of esophagus

38.  In ENT esophagoscopy is done mainly
for foregion body removal.
 In adult patients it can be done in
minimal sedation
 But for paediatric patients general
anaesthesia with endotracheal
intubation is recommended.
 Foreign body can get dislodged in
airway while removing

39.  Symptoms-
 Most common site of impaction is
cricopharynx
 Starvation
 Preoperative evaluation- X ray neck
 Induction
 Small sized endotracheal tube
 Intra operative monitoring

40.  Intraoperative Complications
 1. Esophageal perforation which may
lead to pneumothorax (Right > Left).
 2.Mediastinitis
 2. Compression of endotracheal tube.
 3. Dysrhythmia.
 4. Aspiration.
 5. Accidental extubation.
 6. Stridor secondary to subglottic
edema