To save content items to your account,
please confirm that you agree to abide by our usage policies.
If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your account.
Find out more about saving content to .
To save content items to your Kindle, first ensure email@example.com
is added to your Approved Personal Document E-mail List under your Personal Document Settings
on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part
of your Kindle email address below.
Find out more about saving to your Kindle.
Note you can select to save to either the @free.kindle.com or @kindle.com variations.
‘@free.kindle.com’ emails are free but can only be saved to your device when it is connected to wi-fi.
‘@kindle.com’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.
Patients undergoing ear nose and throat (ENT, otorhinolaryngeal) surgery probably present more airway management challenges than any other branch of surgery. ENT procedures encompass a range of operations varying in duration, severity and complexity from simple short cases such as myringotomy, through to complex resection and reconstructive surgeries for head and neck cancer. In all cases the surgical team operates close to the airway and in many within the airway, which is therefore shared with the anaesthetist. In this chapter, the authors discuss in some depth these challenges and how to address them, airway management and ventilation options and strategies including but not limited to awake intubation, different subtypes of jet ventilation, and high flow nasal oxygenation as well recent advances in the field. They further discuss extubation strategies and controversies as well as a plan to manage commonly encountered complications such as bleeding in the airway. For a successful outcome, these ‘shared airway’ procedures require close communication and cooperation between anaesthetist and surgeon, an understanding of each other’s challenges, knowledge of specialist equipment, and a thorough preoperative evaluation to identify potential risk factors for poor perioperative outcomes.
An understanding of anatomy is paramount to the ability to safely anesthetize the head and neck surgery patient. The basic underlying structure of the face is formed by the skull, facial bones and mandible. The cochlear hair cells activate the cochlear nerve, resulting in hearing transmission. The labyrinthine and tympanic portions of the facial nerve lie in close proximity to these structures and may be dehiscent, necessitating lack of neuromuscular blockade and close monitoring of facial movements during certain otologic procedures. The nose projects from the face largely based on the amount of cartilage. The oral cavity therefore includes the lips, buccal mucosa, maxillary and mandibular alveolar ridges/teeth/gingiva, floor of the mouth, hard palate, the retromolar trigone and the anterior oral tongue. Neck anatomy can be significantly altered by cancer or cancer treatments including surgery and radiation or chemoradiation therapy.
This chapter focuses on non-traumatic maxillary procedures and endoscopic maxillary sinus surgery. Successful surgery involves open dialog between the anesthesiologist, ENT surgeon, and at times the plastic surgeon. Salivary gland resection poses technical challenges to both the surgeon and the anesthesiologist. The anesthetic management of these procedures mainly involves preservation of motor function of the face. Salivary gland resection is an example of the integrated efforts of both surgeon and anesthesiologist. The chapter focuses on the surgery of the mandible and temporomandibular joint (TMJ). Surgery for the mandible can range from biopsy to radical mandibular resection. An example of an anesthetic management for reconstructive mandibular cancer surgery is discussed in the chapter. TMJ arthroscopy is an effective minimally invasive technique to reduce pain and improve the mandibular range of motion that can be done safely on an outpatient basis.
This chapter discusses the minimal synopsis of selected airway pathology in terms of associated anesthetic and airway implications. The case types covered are those where awake intubation by some means is often the method of choice. Epiglottitis can occur in adults too but the situation is less dreadful because the adult airway is larger. Retropharyngeal abscess formation may occur from bacterial infection of the retropharyngeal space secondary to tonsillar or dental infections. Airway tumors can be benign or malignant, but regardless of type, suffocation from airway obstruction is always a potential concern. Nasal polyps and polyps elsewhere in the airway can lead to partial or complete airway obstruction. Patients with laryngeal papillomatosis caused by a HPV infection may require frequent application of laser treatment for attempted eradication of the papillomas. Since Ludwig's angina is often associated with trismus, nasal fiberoptic intubation is frequently needed.
The terms neck dissection and laryngectomy describe a wide variety of surgical procedures that attempt to remove a cancer and its main route of spread. Neck dissection is commonly performed during laryngectomy for cancer to prevent and treat any local spread of the primary disease. A careful airway evaluation is an essential part of preparation for a patient undergoing laryngectomy with neck dissection. The treatment of laryngeal cancer has three primary goals: tumor removal, prevention of spread and recurrence, and preservation of organ function (phonation and swallowing) where possible. Neck radiation changes can make airway management difficult as its presence is an independent predictor of failure for both bag-mask ventilation and GlideScope intubation. Systolic blood pressure variation of the arterial line tracing can help guide fluid replacement. Alternatively a central line, at a different location from the neck dissection, can be used.
Anesthesia for pediatric otorhinolaryngologic procedures represents the largest proportion of elective surgery for not only pediatric anesthesiologists but also general anesthesiologists taking care of children. Adenotonsillectomy (T&A) is one of the most commonly performed pediatric surgical procedures, with recurrent tonsillitis or pharyngitis and adenotonsillar hypertrophy as the major indications. Management and maintenance of anesthesia focuses on maintaining the patient's hemodynamic and volume status, guided by fluid therapy or blood transfusion. For urgent tracheotomies the anesthesiologist must determine whether the child can maintain an airway under general anesthesia and can be intubated by standard laryngoscopy or fiberoptic bronchoscopy. Otolaryngologic procedures require proper preoperative evaluation, intraoperative planning and anticipation of postoperative complications to ensure a favorable outcome. Laryngeal surgery can result in postoperative airway compromise, secondary to swelling or laryngo-tracheomalacia. A safe and smooth postoperative recovery can be achieved by anticipation of potential complications and careful planning for prophylaxis, and effective therapy.
The location of Zenker's diverticulum along with the inherent risks of aspiration at any given stage of surgery (pre-, intra- or postoperative periods) adds an element of unique difficulty in the anesthetic approach to these patients. This chapter explores the anesthetic considerations for this unique procedure. The surgical procedure is generally curative and a majority of the patients live symptom-free for the rest of their lifetime. A main concern during the induction period is to safely secure the airway without increasing the risk of aspiration. While regurgitation and aspiration may occur during induction of anesthesia and during intubation, they might still happen even after successful uneventful intubation. Pertinent perioperative evaluation should include detailed cardiovascular and nutritional status evaluation and optimization. Perforation of Zenker's diverticulum may occur during a difficult intubation, or during blind placement of a nasogastric tube.
The paired parotid glands are the largest among the three major salivary glands in the human body. The parotid gland is encapsulated between the superficial and deep layers of the parotid gland fascia (PGF). This chapter discusses the surgical treatment and anesthesia of sialolithiasis. Airway management after parotidectomy with radical neck dissection can be a challenging situation due to aggravating factors like previous neck interventions, radiation therapy, large fluid shift, intraoperative airway manipulation, swollen tissue and residual anesthetic effect. Ductal stone formation and ductal stenosis are common causes of obstructive salivary diseases of the parotid glands. Sufficient anesthetic depth and patient immobility are usually achieved by a balanced anesthetic technique employing relatively large doses of opioid and inhalational agents. Light anesthesia and patient movement lead to serious complications, especially in the absence of neuromuscular blockade.
Diagnostic bronchoscopic procedures are performed every day by both pulmonologists and thoracic surgeons. Diagnostic bronchoscopy is indicated for airway exam, bronchioalveolar lavage, biopsy of airway lesions, autofluorescence bronchoscopy, and narrow band imaging. Endobronchial ultrasound (EBUS) is a minimally invasive procedure that was designed to evaluate mediastinal and hilar lymphadenopathy using a linear array ultrasound probe modified flexible bronchoscope. Electromagnetic navigational bronchoscopy (ENB) is a bronchoscopic procedure that utilizes the principle of GPS to allow the bronchoscopist to reach peripheral lung lesions adjacent to very small distal bronchi. Diagnostic bronchoscopy can be considered an urgent procedure where a definitive diagnosis and/or staging of a known cancer is needed to plan treatment. Advanced diagnostic bronchoscopy can be performed under moderate sedation, monitored anesthesia care or general anesthesia. EBUS and EMN are considered relatively safe procedures. Rare complications and morbidities which can occur are described in this chapter.
Laryngeal framework surgery (LFS) can be divided into four groups: approximation laryngoplasty, expansion laryngoplasty, relaxation laryngoplasty, and tensioning laryngoplasty. Preoperative evaluation by the surgeon of a patient with vocal fold paralysis includes assessment of many factors and is done with subjective and objective methods. Laryngoplasty is a functional surgery, and it is important to have a patient who is able to cooperate during the procedure and be able to verbalize at the surgeon's request. Traditionally the procedure has been done using opioids, benzodiazepines, propofol. General anesthesia is considered by many of the surgeons unacceptable for laryngoplasty due to the need for the patient to verbalize during the procedure for better results. General anesthesia has some advantages, providing a quiet operative field with no laryngeal, cough or swallowing reflexes. The most common procedure reported done under general anesthesia is medialization thyroplasty, with few reports describing arytenoid adduction with or without thyroplasty.
Anesthesia for Otolaryngologic Surgery offers a comprehensive synopsis of the anesthetic management options for otolaryngologic and bronchoscopic procedures. Authored by world authorities in the fields of anesthesiology and otolaryngology, both theoretical concepts and practical issues are addressed in detail, providing literature-based evidence wherever available and offering expert clinical opinion where rigorous scientific evidence is lacking. A full chapter is dedicated to every common surgical ENT procedure, as well as less common procedures such as face transplantation. Clinical chapters are enriched with case descriptions, making the text applicable to everyday practice. Chapters are also enhanced by numerous illustrations and recommended anesthetic management plans, as well as hints and tips that draw on the authors' extensive experience. Comprehensively reviewing the whole field, Anesthesia for Otolaryngologic Surgery is an invaluable resource for every clinician involved in the care of ENT surgical patients, including anesthesiologists, otolaryngologists and pulmonologists.
The majority of septoplasties and rhinoplasties are performed on healthy patients in the outpatient setting; however, occasionally patients present with medical comorbidities or obstructive sleep apnea (OSA). These surgeries can be performed with local anesthesia and sedation or general anesthesia with an LMA or endotracheal tube. The indication for surgery may be purely cosmetic, post trauma, reconstructive after tumor resection or to improve nasal breathing. Many nasal procedures can successfully be performed under local anesthesia with sedation. Operative and recovery times have been shown to be shorter for patients undergoing surgery with local anesthesia with sedation compared with general anesthesia. Bleeding is one of the biggest complications of nasal surgery. Minimization of intraoperative blood loss allows the surgeon to have an operative field which he can visualize well. The main intraoperative concern includes the minimization of bleeding with use of vasoconstrictors and submucosal epinephrine, controlled hypotension and a smooth emergence.