LMA IN ENT SURGERIES

1. LMA IN ENT SURGERIES
DR VIVEK BADADA
MBBS;DNB;FCC;IDCCM
ASSISTANT PROFESSOR
F.H. MEDICAL COLLEGE &
HOSPITAL,AGRA

3. • ENT anaesthesia is a routine part of most
anaesthetists’ work. “The provision of a
clear, free and unobstructed airway is the
principle concern of all ENT procedures

4. • The LMA Flexible™ provided an unobstructed
airway in all patients. The LMA Flexible™
protects the larynx from contamination during
and after the operation until the return of the
patient’s own protective reflexes.
• Williams P. J., Thompsett C., Bailey P. M. Comparison of the reinforced laryngeal mask
airway and tracheal intubation for nasal surgery. Anaesthesia 1995; 50: 987-989.

5. • The use of the laryngeal mask airway
(LMA) for many forms of ENT
surgery is well established across
Europe and the UK.
• has recently come up for renewed debate.
In particular, its safety and reliability for
adenotonsillectomy has been questioned.
• Indeed the endotracheal tube (ETT)
remains the preferred airway device for
adenotonsillectomy on both sides of the
Atlantic.
• there is good evidence, both recent and
established, that the LMA is a safe and
effective alternative to the ETT in the
majority of ENT operations, including
adenotonsillectomy.
• Crucial importance is experience, both
on the part of the anaesthesiologist
and surgeon.

6. •
• EXTERNAL EAR
• - Removal of simple lesions
• Foreign bodies in ext.auditory
canal
• Preauricular
abnormalitiesExostoses
.
MIDDLE EAR AND
MASTOID
Adenoidectomy
Tonsillectomy
Otitis media
Mastoidectomy
Tympanoplasty
Myringoplasty
INNER EAR
• Cochlear transplant surgery
• Endolymphatic sac
decompression
• Labyrinthectomy
COMMON EAR SURGERIES

7. SPECIFIC CONSIDERTIONS
CHOICE OF AIRWAY.
• FACEMASK
short ear surgeries
cumbersome
Improper oxygenation,theatre pollution and inaccurate
monitoring of tidal gases
• 6 LARYNGEAL MASK AIRWAY
• Flexible LMA designed for ent surgeries
• .For minor procedures has an advantage over face mask as it
nullifies all disadvantages
• .Proseal LMA has allowed major surgeries for over 5 hours.
• 7 ENDOTRACHEAL TUBE
• For most long duration surgeries
• .South facing preformed tube can also be used
• Provides airway collection from debris,blood and regurgitated
gastric contents.

8. Practice Recommendations:
• The Flexible LMA is quite suitable for ENT surgery
as it less likely to be kinked or obstructed and easily
accomodates changes in head and neck position. The
same contraindications for use as the LMA apply for
the FLMA. It is also suggested that LMA use should
be avoided in patients who have been diagnosed with
Obstructive Sleep Apnea.
• 1.Maintain constant communication with surgeon
through the entire case.

9. • 2.Use a size smaller than predicted as use of too large an LMA
will impair surgical access to the lower pole of the tonsil.
• 3.Insert FLMA after inducing an adequate depth of anesthesia.
Laryngospasm is almost always the result of an inadequately
anesthetized patient.
• 4.Pilot tube and shaft should be introduced and secured
midline.
• 5.Lubricate the groove of tongue blade of Boyle Davis gag or
lubricate the shaft of the FLMA to prevent the groove of the
tongue blade from catching on the shaft of the FLMA and
dislodging it.
• 6.Vigiliantly monitor ventilation during mouth gag insertion.

10. • 7.If the FLMA is properly inserted, the cuff should not be
visulaized after the surgeon has inserted the Boyle-Davis
mouth gag. The surgical view should be indistinguishable
from an endotracheal tube.
• 8.Orally suction before FLMA removal.
• 9.Consider leaving FLMA insitu until return of protective
reflexes.
• 10.Remove FLMA with cuff inflated to facilitate removal of
blood, secretions, or surgical debris on the dorsal surface
of the

11. • Flexible LMA removed when pts open their eyes to
command
Requires cooperation b/w anaesthesiologist and
surgeonCare required during placement of
surgeonMechanical obstruction by tonsilar gag in 2-20%
• ADVANTAGES
• Avoidance of muscle relaxant
• Superior recovery profile,
• Fewer episodes of
bronchospasm,laryngospasm,bleeding,desaturation
• Less aspiration of blood
• Better protection of lower respiratory tract than
endotracheal tube
• Flexible LMA removed when pts open their eyes to
command

12. • ANAESTHESIA FOR ENT SURGERY
• Difficult intubations, especially extensive tumours involving the head
and neck.
• Previous surgery or radiotherapy distorts the anatomy - limited
mouth opening..
• The major advantage is the ability to insert the LMA blindly and
secure the airway when laryngoscopy is difficult.
• The laryngeal mask has been used in patients with
• Tracheal stenosis,
• Cleft palate
• Pierre robin syndrome [S], and can be used
• As a guide through which a gum elastic bougie, fibreoptic laryngoscope
• To maintain a difficult airway while a tracheostomy is performed .
• ASAI T, FUJISE K,UCHIDA M. Use of the laryngeal mask in a child with tracheal stenosis. Anesthesiology
1991; 75: 9034. BEVERIDGEM.
• Laryngeal mask airway for repair of cleft palate. Anaesthesia 1989; 44: 6567. DENNY NM, DESILVA KD,
WEBBER PA.
• Laryngeal mask airway for emergency tracheostomy in a neonate. Anaesthesia 1990; 45 895. BENUMOF JL.
• Use of the laryngeal mask to facilitate fibrescope-aided tracheal intubation. Anesthesia and Analgesia 1992;
74 3134. DALRYMPLEG, LLOYD E. Laryngeal mask; a more secure airway than intubation. Anaesthesia 1992;
47: 712-3.

13. TONSILLECTOMY
• Adequate surgical access can be achieved,
with no aspiration of blood during operation.
• Recovery in children with the LMA in situ is
significantly better, with less airway
obstruction and better acceptance.
• The major advantage -can be left in place to
secure the airway during the recovery period

14. NASAL SURGERY
• used successfully
• It provides an effective barrier against blood and
secretions
• . Care should be taken to pack only the postnasal
space and oropharynx, as the pack may displace
the mask if placed too deeply.
• Major nasal surgery requires a degree of
controlled hypotension
• The hypertensive response to laryngoscopy
and intubation is reduced

15. LARYNGEAL SURGERY
• Patients presenting for rigid bronchoscopy or laser
surgery may have laryngeal pathology and consequently
present as difficult intubations.
• The laryngeal mask can be inserted at induction of
anaesthesia and used to maintain the airway until
surgery is ready to start. The need to intubate, with the
possibility of disrupting any pathology in the surgical
site, is avoided,
• The LMA can then be removed and a high frequency jet
ventilator or Sanders injector used to provide ventilation
during surgery via the operating laryngoscope
• Use of the LM A in laryngomalacia has been
described
• Vocal cord movement can be assessed using this
method

16. EAR SURGERY
• Paediatric ear surgery - minor procedures such as insertion
of grommets
• Tracheal intubation -postoperative sore throat and subtle
changes in laryngeal function
• The LMA can be used for major ear surgery, with
controlled ventilation if required..
• The reinforced LMA is preferred to the plain LMA as
its flexibility allows greater tolerance to rotation of the head
by the surgeon.
• During the recovery period, coughing and straining
must be avoided as displacement of grafts may occur.
The LMA is well tolerated until the patient is fully awake

17. MAJOR HEAD AND NECK SURGERY
• Major operations -necessitate tracheal intubation.
Recovery prolonged
• Maintenance of the airway after operation difficult
due to head and neck dressings or anatomical
abnormalities.
• The Guedel airway is frequently used after
extubation, but has been associated with causing
airway obstruction [
• Use of the LMA during recovery provides an
unobstructed airway without the need to support
the jaw. Coughing and straining, which may cause
postoperative bleeding, can be avoided.

19. • During the flexible tracheoscopy at the end of surgical
procedure, three patients (3%) in the TT group and seven
patients (6.7%) in the LMA group had blood ...

20. REMEMBER
• The use of an LMA Flexible™ for
intraoral procedures is an advanced use
that requires training, knowledge, and
skills by both surgeons and
anesthesiologists

21. STUDIES
• J Laryngol Otol. 1992 Jan;106(1):28-30.
• The laryngeal mask airway in ENT surgery.
• Daum RE1
, O'Reilly BJ.
• Author information
• Abstract
• We report our experience of using the laryngeal mask airway (LMA)
over a period of 18 months in 217 patients undergoing a variety of
otorhinolaryngological operations. Advantages over conventional
intubation for both patient and surgeon are suggested in both safety,
speed and economy. An inadequate airway, necessitating
replacement of the LMA, only occurred on two occasions whilst
two known cases of difficult intubation easily had their airways secured
by use of the LMA. Protection of the lower airways from secretions,
fluid or blood, arising above the LMA, would appear to be
confirmed.

22. • LMA for ENT First described for use in nasal surgery in 1995.
• Several papers have compared ETT with Reinforced LMA, some using fibreoptic
bronchoscopeto assess airway soiling, some assessing extent of blood soiling of
device
• Most also assess clinical outcome – ease of emergence, extubation, coughing
and desaturation during recovery.
• Surgical field conditions have been judged better with LMA for the first
15mins of surgery
• required lower rates of remifentanil compared to an ETT after that.
• LMA has repeatedly been shown to provide a satisfactory airway for
tonsillectomy, with less bronchospasm, laryngospasm, bleeding and
desaturation compared to the use of an ETT (most trials in kids)
• Most studies showed superior protection of the larynx from soiling with
blood. One study suggested that the incidence of blood in the distal trachea
was higher with an LMA
• . Proseal LMA has been used successfully for prolonged middle ear surgery.
• If a LMA is contraindicated, then topicalisation of the airway may improve
emergence/extubation.

23. DISCUSSION