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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.
'This addition to the body of anesthesia literature is much welcomed … Contributions from both anesthesiologists and surgeons add strength to this book.'
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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 introduces some of the more common otolaryngology instruments used during procedures involving the larynx, trachea, cervical esophagus, pharynx, and paranasal sinuses. Surgery of the larynx, pharynx, and trachea begins with securing the airway with an appropriate device that will allow for adequate ventilation. Many cases of septoplasty and rhinoplasty are performed under local anesthesia with varying degrees of sedation. Transoral robotic surgery is an emerging technology that is becoming more common at tertiary care centers. Surgery of the upper aerodigestive tract deals with diverse pathology that requires a variety of special surgical instrumentation. Given the demands of the surgeon and anesthesiologist, it is crucial for optimal patient care that open communication before, during, and after the procedure be the standard operating protocol. Basic understanding of otolaryngologic instrumentation as described in the chapter will hopefully allow for mutual understanding between the surgical and anesthesia teams.
A thorough preoperative evaluation will provide both anesthesiologist and surgeon valuable information which may alter the course of patient care. Anesthetic preoperative evaluation is composed of four components: patient history, physical examination, laboratory studies, and anesthetic plan. A review of systems examination is usually a useful approach; this includes assessment of cardiac, pulmonary, renal, hepatic, neurological, gastrointestinal, endocrinological/metabolic, musculoskeletal, psychiatric, gynecological and obstetric organ systems. For ENT surgery, most of the time, anesthetic-related reasons for cancellation are due to recent upper respiratory infection or non-compliance with preoperative fasting guidelines. Evaluation of patient capacity sometimes enters into the process of informed consent or refusal in the elderly. Traditionally, anesthesiologists often consider perioperative cardiac and pulmonary events relatively controlled and easily reversible. While most of the ENT procedures are in the low surgical risk category, some of the large elective ENT operations are considered intermediate-risk surgery.
This chapter deals with difficult airway management in the context of otolaryngologic surgery. To a large extent, the airway management technique for otolaryngologic surgery will depend on clinical circumstances as well as the airway management skills of the anesthesiologist and the available equipment. Should intubation be difficult, clinicians can still provide ventilation and oxygenation via face-mask ventilation. Most patients undergoing otolaryngologic surgery have their airway managed via tracheal intubation. Difficult airway management for otolaryngologic surgery relies heavily on the American Society of Anesthesiologists difficult airway algorithm and, particularly, on the use of awake intubation in the spontaneously breathing patient. The use of fiberoptic intubation for the airway management of patients undergoing otolaryngologic surgery is popular because this technique works well in the presence of many kinds of airway pathology. Many clinicians opt to perform this technique under topical anesthesia with the patient only lightly sedated.
This chapter highlights a technique of airway evaluation which is readily available to the anesthesiologist, is minimally invasive, and may provide enough information to reduce the use of awake intubation by providing improved clinical information. Preoperative endoscopic airway examination (PEAE), uses the commonly available flexible intubation scope, and unlike use of the same instrument for awake intubation, requires minimal time and patient preparation because it is well tolerated by patients, mimicking an ordinary office ENT laryngoscopic examination. Patients presenting to the operating room under the care of an otolaryngologist for management (diagnostic or therapeutic) of an airway lesions have, in most cases, undergone a flexible endoscopy in the surgeon's office. PEAE may be performed in the preoperative clinic setting, holding area or operating room. Patients who present with invisible airway pathology (e.g. papillomas, supraglottic masses), which may compromise the clinician's ability to control the airway, can be more thoroughly assessed.
The incidence of difficult airway is higher in patients undergoing ENT surgery and, specifically, in patients undergoing ENT cancer surgery. Even the process of topicalization with local anesthetic can precipitate loss of the airway, as can some of the complications associated with awake intubation (e.g. airway bleeding and laryngospasm). The preoperative interview should also address the possibility of events having occurred since the last anesthetic such as weight gain, laryngeal stenosis from previous airway intervention, airway radiation, facial cosmetic surgery, and worsening temporomandibular joint disorder or rheumatoid arthritis. Prior to awake intubation, premedication is commonly used to reduce secretions, enable adequate topicalization of the airway, reduce the risk of epistaxis, and protect against the risk of aspiration. Depending on the clinical circumstance, intravenous sedation may be useful in allowing the patient to tolerate awake intubation by providing anxiolysis, amnesia, and analgesia.
Anesthesia for head and neck trauma should be approached utilizing the basic principles of advanced trauma life support (ATLS). The general principles for the anesthetic management of other trauma surgery must be applied to ENT trauma operations. The anesthesiologist must act as the primary resuscitator and principal manager of the airway. In the primary survey, the ABCDE sequence of trauma should be performed: airway, breathing, circulation, disability and neurologic status, and exposure and overall evaluation for other injuries. In children, oxygenation and ventilation are best accomplished by a needle cricothyroidotomy. A needle cricothyroidotomy may be used to temporize the patient until a more formal surgical airway is established. Airway management is best performed with knowledge of airway anatomy, an understanding of the impact of the trauma on the airway, and a thoughtful approach to the deployment of different airway devices.
This chapter provides a brief overview of otolaryngologic emergencies. Complete or partial airway obstruction is common in ENT practice and anesthesiologists are familiar with a variety of measures, such as tracheal intubation, to deal with this event. Intubation is often needed in cases of angioedema; this will usually be performed under topical anesthesia with the patient awake or lightly sedated. Airway-related bleeding may occur spontaneously, as with a bleeding tumor, as a consequence of anticoagulation (e.g. for atrial fibrillation), or following surgery (e.g. after UVPP surgery). Posterior epistaxis may be particularly severe, may be accompanied by hematemesis or melena, and may require general anesthesia and intubation as part of the treatment. Airway-related infections such as epiglottitis, retropharyngeal abscess and Ludwig's angina constitute an emergency airway. One approach commonly taken in such cases is awake intubation, especially in conjunction with a fiberscope.
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.
Stridor is noisy inspiration from turbulent gas flow in the upper airway. This chapter discusses the use of Heliox for temporarily treating stridor in the setting of ENT pathology. Stridor has many potential causes. It may occur as a result of foreign bodies, tumor formation, infections, subglottic stenosis, and airway edema, as well as a result of laryngomalacia, subglottic hemangioma, and vascular rings compressing the trachea. Stridor is usually diagnosed on the basis of symptoms and physical examination, with a view to revealing the underlying problem or condition. Chest and neck X-rays, CT scans, and/or MRIs may reveal structural pathology. Flexible fiberoptic bronchoscopy can also be very helpful, especially in assessing vocal cord function or in looking for signs of compression or infection. Heliox administered with a nonrebreathing face mask should be readily available in every operating room suite to assist in the treatment of stridor.
An airway fire is potentially deadly complication that may occur during tracheotomy surgery, during laser surgery and with a number of other procedures. This chapter discusses the prevention and management of airway fires. The anesthesiologist should keep the administered oxygen levels to the minimum needed when a significant potential for an airway fire is present. In general, cases of airway fire call for immediate removal of the endotracheal tube (ETT) and flooding of the field with saline. While this is a reasonable rule of thumb, it should also be noted that there are occasional patients where removal of the ETT would in all likelihood result in irreversible loss of the airway. Some authors have suggested that flooding the surgical site with carbon dioxide will help prevent airway fires during open tracheostomy using cautery.