2. LOCAL ANAESTHESIA
• Followed general anesthesia by 40 years
• Properties : Reversible nerve blockade
• Binds Na+ gated channel
• Prevents propagation of the nerve impulse
• 2 classes : Amides – Lignocaine, Bupivacaine
Prilocaine
Esters : Cocaine. Procaine, tetracaine
• Cocaine : 1st LA used by Karl Koller for
eye surgery (1884)
3. • Lidocaine/Lignocaine : Most commonly used LA agent
• First synthesized in 1943
• Onset < 1 minute
• Duration 1 hour
• 2-3 hours (vasoconstrictor agents).
• With vasoconstrictor : hemostasis + Less systemic
absorption
4. Types of local anaesthesia
Topical anaesthesia using 4% Lignocaine/ 10%
spray
Infiltration anaesthesia using 1%/ 2%
Lignocaine
Regional blocks
• Max. recommended dose : Without Adr :
4.5mg/kg in adults & 3mg/kg in pediatric
With Adr : 7 mg/kg
5. EAR SURGERY
• 2% Xylocaine with Adr in 1:60000 concentration for infiltration
• Preoperative/ intraoperative sedative / anxiolytics : Midazolam
5-7.5mg / meperidine 50-75mg / promethazine 25-50mg /
Pentazocine 30 mg IM/IV
Advantages of LA
• Decreased operative and recovery time
• Ability to assess facial nerve function
• Less Bleeding
• Less expensive
6. • Auriculotemporal (V3)
• Greater auricular
• Auricular Br. of Vagus (Arnold’s
nerve) + facial
• Lesser Occipital
• Canal : Auriculotemporal Vagus
Facial
• TM Lateral surface : AT & V
• Medial surface : Tympanic br. of CN
IX ( Jacobson’s nr)
NERVE SUPPLY
8. The needle is advanced anteriorly
through the same entry under the
concha and 0.5 ml is injected in
the posterior (2), the superior (3)
and inferior (4) meatal walls
Another 0.5 ml is injected in front
of the helix crus (5) to block
auriculotemporal nerve
9.
10. Temporary facial nr paresis
Grommet tube insertion: infiltration of 5ml on ext. meatus & topical
application of lidocaine on TM surface
Topical application for intra-tympanic injection of drugs
LA for auricular procedures : steps 1-5 & around lesion in preauricular
sinus excision
Middle ear mucosa : gel foam or cotton soaked in AS
General anesthesia : Nitrous oxide is either entirely avoided during
tympanoplasty or discontinued prior to graft placement
Intraoperative facial nerve monitoring - neuromuscular paralysis to be
worn off
11. NOSE SURGERY
Choice of anaesthesia depends
• Patient factor
• Duration
• Site
• Complexity
General Anaesthesia : independence from patient cooperation and control
of airway
Local anaesthesia :Improved surgical field
Patient can report manipulation of orbital periosteum & dura.
12. NERVE SUPPLY OF NOSE
• Infratrochlear nr
• External nasal branch
of anterior ethmoidal
nr
• Infraorbital nr
14. MUCOSAL SURFACE ANAESTHESIA
10% xylocaine nasal spray: Topical surface
anesthesia ( 45 mins)
Nasal packing : cottonoids / pledgets soaked
in 4% xylocaine mixed with 1:30000
adrenaline
Each nasal cavity should be packed with 3
packs.
15. • Just above the attachment of Middle
turbinate,
• Anterior end of middle turbinate
• Back end of middle turbinate
• Uncinate process
• Over inferior turbinate
• medial surface of middle turbinate
• nasal septum
INFILTRATION ANAESTHESIA
17. EXTERNAL NOSE
•Fanshape injection at nasion : Supratrochlear & infra trochlear nerve
•Between nasal dorsum and cheek : Anterior ethmoidal nerve
18. NASOCILIARY NERVE BLOCK
Near anterior ethmoidal
foramen
26 G needle inserted 1 cm
above the medial canthus,
halfway between the posterior
palpebral fold and the eyebrow
Directed medially and
backward to contact the bony
roof of the orbit
At a depth of 1.5 cm, the needle
should be at the anterior
ethmoidal foramen (1-2ml)
24. LARYNGEAL BLOCK
• Superior laryngeal Block
• Recurrent laryngeal
Block
• Mainly for awake
intubation
• Bronchoscopy
• DL Scopy
• In adjuvant with
Glossopharyngeal block
25. GLOSSOPHARYNGEAL NERVE BLOCK
External approach
Midway between
mastoid process and
angle of mandible
Advanced till styloid
process is contacted
Withdraw and direct 1
cm posteriorly
Aspirate and inject 3-
5cc
26. • Intraoral technique
Submucosally in caudal
portion of posterior tonsillar
pillar
Or to a depth of 5mm from
caudal portion of anterior
pillar
28. Apnoeic oxygenation
• Now historic
• Pre oxygenation of patient with 100% O2 with a brief period of
instrumentation till saturation drops to 88-90% ( safe apnoea )
• Followed by removal of instruments from bronchoscope and capping the
proximal end enabling anaesthetist to ventilate
• Anesthesia maintained with repeated injections/infusion of IV drugs &
ventilation assisted in case of apnea or desaturation
• Risk of respiratory acidosis
29. SPONTANEOUS ASSISTED VENTILATION
• Pre-oxygenation for 3mins
• Induction of anaesthesia with intravenous agents
• Titrated so that patient can maintain spontaneous ventilation
• Bronchoscope is introduced and the patient is ventilated with high flow oxygen
through ventilatory port
• the ventilation is assisted manually in case of prolonged apnea or desaturation
30. Controlled ventilation
• Most commonly used method of ventilation
• Bronchoscope used like ET tube for positive pressure ventilation
• Silastic caps placed on ports of rigid scope
• Oropharynx packed to minimize air leak
• Patients are given muscle relaxants
31. JET VENTILATION
High pressure gas source is applied to open
airway in small bursts via small catheter
2 techniques : manual and high frequency
Manual:
Described by Sanders in 1967
Hand operated valve connected to 100%
oxygen and the pressure is delivered at 50 psi
or less with respiratory rate between 10 and
14 breaths/min
32. • Jet ventilation applied by narrow bore cannula attached bronchoscope
• Jet frequency of 8–10/min
• Monitoring of tidal volume (VT) becomes difficult because the system is open
High frequency jet ventilation
• Delivery of small tidal volume at high respiratory rates of 60–300
breaths/min
• High respiratory rate and low VT gives a motionless procedure field
34. MLS/LASER SURGERY
• Risk of airway fire : Oxidizing source, heat,
Fuel
• Laser resistant , non inflammable, flexible
stainless steel tube
• proximal cuff with saline/methylene blue
• saline-soaked pledgets should be placed in the
airway, and water should be immediately
available in a 50 cc syringe
