ANAESTHESIA FOR EAR SURGERY COMMON SURGERIESExternal ear Removal

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ANAESTHESIA FOR EAR SURGERY COMMON SURGERIESExternal ear • Removal of simple lesions • Foreign

ANAESTHESIA FOR EAR SURGERY COMMON SURGERIESExternal ear • Removal of simple lesions • Foreign bodies in ext. auditory canal • Preauricular abnormalities • Exostoses

MIDDLE EAR AND MASTOID • Adenoidectomy • Tonsillectomy • Otitis media • Mastoidectomy •

MIDDLE EAR AND MASTOID • Adenoidectomy • Tonsillectomy • Otitis media • Mastoidectomy • Tympanoplasty • Myringoplasty

INNER EAR • Cochlear transplant surgery • Endolymphatic sac decompression • Labyrinthectomy

INNER EAR • Cochlear transplant surgery • Endolymphatic sac decompression • Labyrinthectomy

TECHNIQUE OF ANAESTHESIA GENERAL ANAESTHESIA • A through preoperative asessment advised. • Specific attention

TECHNIQUE OF ANAESTHESIA GENERAL ANAESTHESIA • A through preoperative asessment advised. • Specific attention paid to hypertension or any cardivascular disease which limits attempts to control BP introp. • No specific premedication required • Anxiolytics such as alprolazam and temazepam for anxious patients. • Beta blocker or clonidine if required can be given iv with intraop monitoring

SPECIFIC CONSIDERTIONS. . CHOICE OF AIRWAY. . FACEMASK • Earlier used for short ear

SPECIFIC CONSIDERTIONS. . CHOICE OF AIRWAY. . FACEMASK • Earlier used for short ear surgeries such as myringotomy and tube insertion • Was cumbersome for both anaesthesiologist and surgeon • Improper oxygenation, theatre pollution and inaccurate monitoring of tidal gases are major diasadvantages.

LARYNGEAL MASK AIRWAY • Flexible LMA designed for ent surgeries. • Has a flexible

LARYNGEAL MASK AIRWAY • Flexible LMA designed for ent surgeries. • Has a flexible shaft wich is more tolerant to head rotation and flexion and extension. • For minor procedures has an advantage over face mask as it nullifies all disadvantages. • Proseal LMA has allowed major surgeries for over 5 hours.

ENDOTRACHEAL TUBE • For most long duration surgeries a reinforced or armored tracheal tube

ENDOTRACHEAL TUBE • For most long duration surgeries a reinforced or armored tracheal tube needed to prevent kinking with head rotation. • South facing preformed tube can also be used • Provides airway collection from debris, blood and regurgitated gastric contents.

NITROUS OXIDE • Nitrous oxide diffuses from blood to airspaces. • Amount depends on

NITROUS OXIDE • Nitrous oxide diffuses from blood to airspaces. • Amount depends on concenteration and duration of surgery. • Causes increase in middle ear pressures during surgery • Excessive negative pressures after discontinuation of N 2 O can cause displacement of graft.

 • Underlay grafts have decreased graft displacement. • Many anaesthesiologists use nitrous oxide<50%

• Underlay grafts have decreased graft displacement. • Many anaesthesiologists use nitrous oxide<50% CONC in middle ear surgeries

POSITION • Rotation and flexion of head is necessary in most ear surgeries •

POSITION • Rotation and flexion of head is necessary in most ear surgeries • Measures to prevent compression of jugular and carotid considered. • Lateral tilt of ot table improves surgical access. • Arms should be placed in neutral position • Head up by 15 deg reduces venous pressure and improves operative field.

 FACIAL NERVE MONITORING • Used for middle ear, mastoid and inner ear surgeries

FACIAL NERVE MONITORING • Used for middle ear, mastoid and inner ear surgeries to identify the facial nerve. • Audible and visual signals recorded in the monitor. • Partial or complete neuromuscular blockade abolishes this activity • Essential to reverse the nm blockade and asssess the nerve before proceeding dissection near it.

ANTIEMETICS • Middle ear and inner procedures have a higher complications rate • Retching

ANTIEMETICS • Middle ear and inner procedures have a higher complications rate • Retching and vomiting also increase venous pressure, and icp or disrupt surgical grafts. • Opoids if possible should be avoided. • Antiemetics like ondansetron, droperidol, scopolamine, dexamet hasone and prokinetics like metoclopramide may be used.

 • • For all long surgeries… Dvt prophylaxis advocated. Temperature monitoring done Urinary

• • For all long surgeries… Dvt prophylaxis advocated. Temperature monitoring done Urinary catheterisation be considered.

LOCAL ANAESTHESIA • Can be undertaken safely in suitable patients with or without sedation

LOCAL ANAESTHESIA • Can be undertaken safely in suitable patients with or without sedation • Preop asessment and intraop monitoring same as for general anaesthesia • Simple external, and some middle ear surgeries in LA • Light sedation with midazolam and propofol • Patient understanding and cooperation vital • LA can be in form of infiltrating lidocaine , topical administration of lidocaine onto tympanic membrane

NERVE BLOCK Infiltration of Anterior and posterior meatal wall-Auriculotemporal nerve, Greater auriculur nerve Aural

NERVE BLOCK Infiltration of Anterior and posterior meatal wall-Auriculotemporal nerve, Greater auriculur nerve Aural speculum-Auriculur branch of vagus Topical application of LA-tympanic nerve

ANAESTHESIA FOR NASAL SURGERY TYPES OF NASAL SURGERY • Procedures on external aspect of

ANAESTHESIA FOR NASAL SURGERY TYPES OF NASAL SURGERY • Procedures on external aspect of nose • “ within nasal cavity • “within nasal sinuses • “involving the bony structures

 SURGERIES UNDER GENERAL ANAESTHESIA • Sinus surgeries • Rhinoplasty • Septorhinoplasty • Nasolacrimal

SURGERIES UNDER GENERAL ANAESTHESIA • Sinus surgeries • Rhinoplasty • Septorhinoplasty • Nasolacrimal duct surgery • Frontal sinus surgeries • Ant skull base surgeries • Cranofacial resections

 SURGERIES UNDER LOCAL ANAESTHESIA Procedures on anterior septum Septoplasty Turbinectomy Cauterisation Polypectomy Reduction

SURGERIES UNDER LOCAL ANAESTHESIA Procedures on anterior septum Septoplasty Turbinectomy Cauterisation Polypectomy Reduction of simple nasal fractures

Preoperative evaluation Same for local and general anaesthesia Specific asessment for • Obstructive sleep

Preoperative evaluation Same for local and general anaesthesia Specific asessment for • Obstructive sleep apnea • Use of nasal cpap • Cardiovascular status • History of Nsaid use • Samter triad-inc incidence of brochospasm

NASAL VASOCONSTRICTORS • Reduce bleeding from nasal mucosa • Can be used in combination

NASAL VASOCONSTRICTORS • Reduce bleeding from nasal mucosa • Can be used in combination with local anaesthetics • Phenylephrine+lidocaine, lidocaine+epinephrin e

CHOICE OF AIRWAY Adequate throat packing be done to protect lower airway Both flexible

CHOICE OF AIRWAY Adequate throat packing be done to protect lower airway Both flexible LMA and endotracheal tube can be used. Exam by fibreoptic scope revealed superior lower airway protection by a correctly placed LMA than a endotracheal tube. Towards end of surgery throat pack must be removed with careful examination of oral and postnasal space accompnied by suctioning.

EXTUBATION Extubation of tube when pt awake or deep Extubation of flexible LMA when

EXTUBATION Extubation of tube when pt awake or deep Extubation of flexible LMA when patient can open mouth to command. Awake extubation(Adv-better and quicker laryngeal reflexes and hence lesser chances of lower airway contamination) Disadvantage-higher incidence of laryngospasm, bucking, desaturation

Deep extubation: Adv • Improves recovery profile, • lesser chances of laryngospasm Disadvantage •

Deep extubation: Adv • Improves recovery profile, • lesser chances of laryngospasm Disadvantage • leaves an unprotected airway • dangerous in pts of OSA

POSTOPERATIVE CONSIDERATION Almost all pts have complete or partial airway obstruction. Significant in OSA

POSTOPERATIVE CONSIDERATION Almost all pts have complete or partial airway obstruction. Significant in OSA patients can have nasopharangeal airway incorporated into nasal pack Pain is usually mild so oral aceaminophen and a NSAID are adequate. IV canula to be retained till removal of nasal pack

ANAESTHESIA FOR THROAT SURGERY INTRAORAL SURGERY • TONSILLECTOMY • ADENOIDECTOMY • PALATAL SURGERY LARYNGEAL

ANAESTHESIA FOR THROAT SURGERY INTRAORAL SURGERY • TONSILLECTOMY • ADENOIDECTOMY • PALATAL SURGERY LARYNGEAL PROCEDURES • BENIGN, MALIGNANTAND STENOTIC LESIONS • AIRWAY ENDOSCOPY • LASER SURGERY

Preoperative assessment • • Identify patients with OSA Loose teeth Vunerable dental implants Bleeding

Preoperative assessment • • Identify patients with OSA Loose teeth Vunerable dental implants Bleeding disorders Anaemia Active infection Sickle cell disease status RTI infections inc risk of bleeding, surgery should be postponed

GENERAL ANAESTHESIA • Maintain sufficient of anaesthesia • IV induction with propofol, fentanyl with

GENERAL ANAESTHESIA • Maintain sufficient of anaesthesia • IV induction with propofol, fentanyl with a short acting muscle relaxant • Inhaled induction in uncooperative children, and needle phobic adults • Inhalational induction can be dangerous in pts with OSA • During procedure both spontaneous and ippv can be used

 • Oral packing must be done adequately • During spontaneous ventilation constant observation

• Oral packing must be done adequately • During spontaneous ventilation constant observation of reservoir bag done. • Timing of extubation to reduce incidence of laryngospasm ANALGESIA: • Tonsillectomy more painful in adults , so adequate intraoperative and postoperative analgesia must be provided • Intraoperative opoids usually necessary • Role of Aspirin in analgesia controversial

STEROIDS • IV dexamethasone. 05 -. 15 mg/kg improves recovery • Decrease postoperative emesis

STEROIDS • IV dexamethasone. 05 -. 15 mg/kg improves recovery • Decrease postoperative emesis • Increased tolerance to regular diet • Analgesia ANTIBIOTICS Reduce fever , halitosis Earlier return to normal oral intake No effect on analgesia

POSTOPERATIVE NAUSEA AND VOMITING Ondansetron, granisetron, dexamethasone have good antiemetic effect Ondansetron. 15 mg/kg

POSTOPERATIVE NAUSEA AND VOMITING Ondansetron, granisetron, dexamethasone have good antiemetic effect Ondansetron. 15 mg/kg better than metoclopramide . 25 mg/kg Pt should be well hydrated and receive regular non opioid analgesia postoperatively.

Post extubation laryngospasm and stridor • Incidence more after removal of tube than flexible

Post extubation laryngospasm and stridor • Incidence more after removal of tube than flexible LMA • Incidence-12 -25% • Methods of reducing laryngospasm • Topical lidocaine 2 -4% application • IV lidocaine 1 mg/kg • Administration of propofol close to extubation • IV magnesium also used

CHOICE OF AIRWAY Choice of tracheal tube, flexible LMA depend on experience of anaesthesiologist

CHOICE OF AIRWAY Choice of tracheal tube, flexible LMA depend on experience of anaesthesiologist Flexible LMA should be only used by experienced anaesthesiologist

TRACHEAL TUBE: Southfacing endotracheal tube Most common way of airway maintainance More resistant to

TRACHEAL TUBE: Southfacing endotracheal tube Most common way of airway maintainance More resistant to compression from mouth gag Less likely to obstruct during surgery Occupies less space in oropharanynx than flexible LMA During extubation careful laryngoscopy is done with suctioning to ensure no blood clots are present Pt placed in tonsil position Extubation deep or awake

FLEXIBLE LMA: Requires cooperation b/w anaesthesiologist and surgeon Care required during placement of surgeon

FLEXIBLE LMA: Requires cooperation b/w anaesthesiologist and surgeon Care required during placement of surgeon Mechanical 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

Anaesthetic considerations for Bleeding tonsil • Incidence of postop haemorrhage increase with age •

Anaesthetic considerations for Bleeding tonsil • Incidence of postop haemorrhage increase with age • Primary bleeds occur within 6 hrs of surgery • Bleeding is usually venous or capillary • Signs are tachycardia, hypotension, excessive swallowing, pallor , restlessness, airway obstuction • Help of a senior anaesthesiologist seeked

 • Pts should be given oxygen • Large bore IV access should be

• Pts should be given oxygen • Large bore IV access should be established. • Haemoglobin , haematocrit , coagulation status assessed. • laryngoscopy can be difficult because of clots. continuous oozing, intraoral swlling. • Post resustication RSI is preferred. • Smaller sized ET tubes should be available • After intubation ryle tube inserted to evacuate swallowed blood • Inhaled induction difficult is lateral position • More chances of laryngospasm • Extubation done when pt fully awake.

ANESTHESIA FOR LARYNGEAL SURGERIES Anesthesiologist and the surgeon are working in the same anatomic

ANESTHESIA FOR LARYNGEAL SURGERIES Anesthesiologist and the surgeon are working in the same anatomic field P ts presentwith minor vocal cord lesions to elderly patients with glottic carcinoma and stridor The anesthesiologist has to maintain oxygenation, remove carbon dioxide, protect the airway, and keep the patient anesthetized, while the surgeon is operating in the same area. Cooperation and communication between the anesthesiologist and the surgeon are essential for success.

VOCALCORD PATHOLOGIES 1. Nodules. 2. Polyps 3. Cysts. 4. Granulomas. 5. Papillomas. 6. Malignant

VOCALCORD PATHOLOGIES 1. Nodules. 2. Polyps 3. Cysts. 4. Granulomas. 5. Papillomas. 6. Malignant

Preoperative Assessment Anesthesiologist should have some idea of the size, mobility, and location of

Preoperative Assessment Anesthesiologist should have some idea of the size, mobility, and location of the lesion Standard airway assessments to predict the ease of ventilation, visualization of the laryngeal inlet, and tracheal intubation should be performed. Airway pathology and its impact on airway severity and size of lesions at the glottic level are assessed by direct or indirect laryngoscopy. Subglottic and tracheal lesions assessed by chest radiography, computed tomography (CT), and magnetic resonance imaging (MRI).

Assessment Implication History of endoscopic procedures -Any previous difficulty is significant, and anesthetic records

Assessment Implication History of endoscopic procedures -Any previous difficulty is significant, and anesthetic records should be reviewed to assess severity and site of obstruction, vascularity of lesion, and previous anesthetic techniques used Hoarse voice -Nonspecific symptom; patients can be hoarse with only minor lesions on the vocal cord or have significant vocal cord pathology and airway compromise Voice changes- Nonspecific symptom; minor lesions can result in significant voice changes Dysphagia- Significant and suggests supraglottic obstruction; if associated with carcinoma implies upper esophageal extension Altered breathing position- Significant; patients with partially obstructing lesions compensate by changing their body positioning to limit airway obstruction Unable to lie flat Significant- suggests severe airway obstruction, and patients may need to sleep upright

Breathing during sleep -Significant; difficulty in breathing at night or waking up at night

Breathing during sleep -Significant; difficulty in breathing at night or waking up at night in a panic suggests severe obstruction Stridor- Significant; indicates critical airway obstruction with >50% reduction in airway diameter and in adults an airway diameter of 4 -5 mm Stridor on exertion -Significant; suggests airway obstruction is becoming critical; patients may have no stridor at rest Significant- critical airway obstruction is present Inspiratory stridor- Significant; suggests extrathoracic airway obstruction Expiratory stridor- Significant; suggests intrathoracic airway obstruction

 • Absence of stridor- Generally reassuring, but in exhausted adults and children there

• Absence of stridor- Generally reassuring, but in exhausted adults and children there are limited chest movements and insufficient airflow to generate enough turbulent flow for stridor • Fiberoptic awake flexible laryngoscopy - Necessary for All adult patients should have this to visualize the vocal cords, great care must be taken to avoid local anesthetic and fiberscope contact with the vocal cords, precipitating total airway obstruction • Chest x-ray/CT/MRI scans- Can identify severity and depth of glottic, subglottic, tracheal, and intrathoracic lesions

ANAESTHETIC CONSIDERATIONS FOR ENDOSCOPY Technique depends on Pt general condition Size mobility and location

ANAESTHETIC CONSIDERATIONS FOR ENDOSCOPY Technique depends on Pt general condition Size mobility and location of lesion Use of laser Surgical requirements

An ideal technique: (1)Is simple to use (2)Provide complete control of the airway with

An ideal technique: (1)Is simple to use (2)Provide complete control of the airway with no risk of aspiration; (3) Control ventilation with adequate oxygenation and carbon dioxide removal; (4) Provide smooth induction and maintenance of anesthesia; (5) Provide a clear motionless surgical field, free of secretions; (6) Not impose time restrictions on the surgeon; (7) Not be associated with the risk of airway fire or cardiovascular instability; (8) Allow safe emergence with no coughing, bucking, breath holding, or laryngospasm; (9) Produce a pain-free, comfortable, alert patient at the end of the operation.

Cuffed tube protects airway but can obscure view Most of them are not laser

Cuffed tube protects airway but can obscure view Most of them are not laser safe Anaesthetic techniques classified into 1. Closed system 2. Open system

Closed system: cuffed tracheal tube is employed with protection of the lower airway Open

Closed system: cuffed tracheal tube is employed with protection of the lower airway Open system: cuffed tracheal tube is absent using either spontaneous ventilation and insufflation techniques or muscle paralysis and jet ventilation.

Advantages of closed system (1)routine technique for all anesthesiologists, (2) protection of the lower

Advantages of closed system (1)routine technique for all anesthesiologists, (2) protection of the lower airway, (3) control of the airway, (4) control of ventilation, (5) minimal pollution by volatile agents

Disadvantages: (1) surgical access and visibility of the lesion may be limited, (2) high

Disadvantages: (1) surgical access and visibility of the lesion may be limited, (2) high inflation pressure may be required through small tubes, (3) tube-related damage to the vocal cords during intubation, (4) risk of a laser airway fire.

 Advantages of an open system (1) laser safety, (2) reduced risk of tube-related

Advantages of an open system (1) laser safety, (2) reduced risk of tube-related trauma, (3) complete laryngeal visualization. The disadvantages are (1) an unprotected lower airway and (2) specialist knowledge, equipment, and experience are required.

Closed System—Intubation Techniques Microlaryngoscopy Tubes • Are long, have a small internal and external

Closed System—Intubation Techniques Microlaryngoscopy Tubes • Are long, have a small internal and external diameter • Designed specifically for endoscopy procedures. 4 - to 5 -mm internal diameter tubes with high-volume, low-pressure cuffs used in nasal or oral versions. • Not suitable for laser surgery

LASER TUBES: • Lasers used for the resection of papillomas, vascular lesions of the

LASER TUBES: • Lasers used for the resection of papillomas, vascular lesions of the vocal cord, granulomas, and laryngeal carcinoma. • Carbon dioxide lasers are the most commonly used in airway surgery • Laser-proof tube is the all-metal Norton tube, which has no cuff. • Most laser tubes have laser-resistant properties around the shaft • Cuff is the least protected part of the tube

Open Systems—Nonintubation Techniques Spontaneous Ventilation and Insufflation Technique: Useful in the removal of foreign

Open Systems—Nonintubation Techniques Spontaneous Ventilation and Insufflation Technique: Useful in the removal of foreign bodies Evaluation of airway dynamics (tracheomalacia Removal of noncompromised glottic and subglottic lesions. Requires a spontaneously breathing patient and provides a clear view of an unobstructed glottis

TECHNIQUE IN OPEN SYSTEM Inhaled induction is begun with sevoflurane in 100% oxygen At

TECHNIQUE IN OPEN SYSTEM Inhaled induction is begun with sevoflurane in 100% oxygen At suitable depth laryngoscopy performed with topical lignocaine administration above and below the vocal cords One hundred percent oxygen is administered by facemask with spontaneous ventilation Anesthesia is continued with inhalation (insufflation) or an intravenous route (propofol infusion). At a suitable depth the surgeon undertakes laryngoscopy or bronchoscopy

Routes of insufflation: (1) A small catheter introduced into the nasopharynx and placed immediately

Routes of insufflation: (1) A small catheter introduced into the nasopharynx and placed immediately above the laryngeal opening (2) A tracheal tube cut short and placed through the nasopharynx emerging just beyond the soft palate (3) A nasopharyngeal airway (4) The side-arm or channel of a laryngoscope or bronchoscope.

 Limitations of spontaneous ventilation or insufflation techniques: 1. Lack of control over ventilation

Limitations of spontaneous ventilation or insufflation techniques: 1. Lack of control over ventilation and the potential for airway soiling. 2. Operating room pollution secondary to insufflation of volatile agents 3. May be unsuitable for large, soft, floppy lesions, particularly in the supraglottis or glottis, which may obstruct the airway after the onset of general anesthesia with spontaneous ventilation.

JET VENTILATION TECHNIQUES SUPRAGLOTTIC JET VENTILATION SUBGLOTTIC JET VENTILATION TRANSTRACHEAL JET VENTILATION

JET VENTILATION TECHNIQUES SUPRAGLOTTIC JET VENTILATION SUBGLOTTIC JET VENTILATION TRANSTRACHEAL JET VENTILATION

SUPRAGLOTTIC JET VENTILATION A technique in which the jet of gas emerges in the

SUPRAGLOTTIC JET VENTILATION A technique in which the jet of gas emerges in the supraglottis by attachment of a jetting needle to the rigid surgical suspension laryngoscope. High-frequency or low-frequency ventilation can be used. Allow a clear, unobstructed view for the surgeon with no risk of a laser airway fire Use of LMA provides a smooth recovery from anaesthesia

LIMITATIONS: (1) Misalignment of the suspension laryngoscope to the glottic inlet, which results in

LIMITATIONS: (1) Misalignment of the suspension laryngoscope to the glottic inlet, which results in poor ventilation (2) Risk of gastric distention with entrained air (3) Blood, smoke, and debris are blown into the distal trachea (4) Considerable vibration and movement of the vocal cords occurs, which may require ventilation to be stopped while operating (5) Inability to monitor end-tidal carbon dioxide concentration; and (6) Risk of barotrauma with pneumomediastinum, pneumothorax, and subcutaneous emphysema.

Subglottic Jet Ventilation Allows delivery of a jet of gas directly into the trachea

Subglottic Jet Ventilation Allows delivery of a jet of gas directly into the trachea by the placement of a small catheter through the glottis and into the trachea ADVANTAGESMore efficient than supraglottic jet ventilation 1. Reduced driving pressures 2. Minimal vocal cord movements 3. A good surgical field 4. No time constraints for the surgeon in the placement of the rigid laryngoscope

Disadvantages: 1. Potential for a laser-induced airway fire 2. Presence of a potential fuel

Disadvantages: 1. Potential for a laser-induced airway fire 2. Presence of a potential fuel source within the airway, and a greater risk of barotrauma than in supraglottic jet techniques.

TRANSTRACHEAL JET TECHNIQUES Under local anaesthesia for significant airway pathology Under GA for elective

TRANSTRACHEAL JET TECHNIQUES Under local anaesthesia for significant airway pathology Under GA for elective laryngeal surgery Limitations: • carry the greatest risks of barotrauma. • blockage • kinking • infection • bleeding • failure to site the catheter

Inhaled Foreign Bodies Foreign body aspiration is the most common indication for bronchoscopy in

Inhaled Foreign Bodies Foreign body aspiration is the most common indication for bronchoscopy in children 1 to 4 years old. foreign bodies can lodge in the larynx, trachea, main bronchi, or smaller airways effects depend on the duration, degree, and site present with acute dyspnea, stridor, coughing, and cyanosis.

ANAESTHETIC CONSIDERATIONS: Spontaneous ventilation preferred to reduce the chances of the foreign body being

ANAESTHETIC CONSIDERATIONS: Spontaneous ventilation preferred to reduce the chances of the foreign body being pushed distally into the airway And intermittent positive-pressure ventilation may be needed Sedative premedication should be avoided because it may precipitate total airway occlusion.

Induction is usually by an inhaled technique with sevoflurane or halothane in oxygen At

Induction is usually by an inhaled technique with sevoflurane or halothane in oxygen At a deep plane of anesthesia, laryngoscopy is performed, and topical local anesthetic (lidocaine) is administered Intravenous anticholinergic agents (atropine, 20 µg/kg, or glycopyrrolate, 10 µg/kg) dec. secretions and reflex bradycardia associated with airway instrumentation. Correct depth of anaesthesia maintained in the procedure by IV propofol

Some bronchoscopes allow the attachment of a Tpiece to a side arm on the

Some bronchoscopes allow the attachment of a Tpiece to a side arm on the bronchoscope Oxygen and volatile agent can pass directly into the distal trachea through them In some bronchoscopes insufflation techniques are required for ventilation IV dexamethasone. 1 mg/kg to reduce airway edema postoperatively. Humidified oxygen and antibiotics also needed postoperatively In some pts hdu care may be required for intensive monitoring

HEAD AND NECK SURGERY Laryngectomy Pharyngolaryngectomy Radical neck dissection Resection of large thyroid lesions

HEAD AND NECK SURGERY Laryngectomy Pharyngolaryngectomy Radical neck dissection Resection of large thyroid lesions

GENERAL CONSIDERATIONS More than 80% of laryngeal and oropharyngeal cancers are found in men

GENERAL CONSIDERATIONS More than 80% of laryngeal and oropharyngeal cancers are found in men 40 to 75 years Greater than 97% of patients are smokers with a high alcohol intake. Patients may have had Previous radiotherapy and surgery resulting in altered anatomy, tissue edema, induration, and “stiff” tissues

PREOPERATIVE EVALUATION assessment of alcohol intake use of tobacco nutritional status electrolyte disturbance. chronic

PREOPERATIVE EVALUATION assessment of alcohol intake use of tobacco nutritional status electrolyte disturbance. chronic obstructive pulmonary disease, hypertension, and coronary artery disease, should be assessed.

Intraoperative considerations Major surgeries involve potential for blood loss. Monitoring including intra-arterial blood pressure

Intraoperative considerations Major surgeries involve potential for blood loss. Monitoring including intra-arterial blood pressure and central venous pressure should be strongly considered. CVP lines should be placed in anticubital or femoral vein Surgical manipulation around carotid sinus can produce reflex bradycardia or even asystole In the above case surgery should be stopprd and resustication started Local infiltration of lignocaine can also be done prophlactically.

Some degree of hypotension is usually required Can be achieved with inhaled agents and

Some degree of hypotension is usually required Can be achieved with inhaled agents and a 10 - to 15 -degree head-up tilt aiming for systolic blood pressures of around 85 to 90 mm Hg. A remifentanil infusion also is very effective in controlling the stress response during surgery

HEAD AND NECK DIFFICULT AIRWAY Caused by numerous disease states at different levels within

HEAD AND NECK DIFFICULT AIRWAY Caused by numerous disease states at different levels within the airway No single anesthetic management technique can be used safely in all patients.

LEVEL OF OBSTRUCTION: (1) Oral cavity (2) Oropharynx (3) Tongue base and supraglottis (4)

LEVEL OF OBSTRUCTION: (1) Oral cavity (2) Oropharynx (3) Tongue base and supraglottis (4) Glottis (5) Subglottic and upper trachea (6) Midtracheal (7) Lower tracheal and bronchial.

Oral Cavity and Oropharyngeal Lesions Small oral lesions such as tonsilar carcinoma usually do

Oral Cavity and Oropharyngeal Lesions Small oral lesions such as tonsilar carcinoma usually do not obstruct the airway. Standardised airway management rechniques may be adequate for non compromised For larger lesions in the oral cavity, partial or near-complete airway obstruction can be a feature Iv induction causes loss of airway tone Large lesions cause an inability to oxygenate hence facemask may not be helpful

Passage of an oral or nasal airway past large, obstructing, vascular, necrotic oral tumors

Passage of an oral or nasal airway past large, obstructing, vascular, necrotic oral tumors causes trauma and bleeding An awake fiberoptic intubation technique is often used in this group of patients Other anesthetic techniques include awake transtracheal catheter placement with jet ventilation and awake tracheostomy

Abscess and Ludwig's Angina: Minor abscess causes pain and swelling only. Abscesses around the

Abscess and Ludwig's Angina: Minor abscess causes pain and swelling only. Abscesses around the peritonsillar area also may lead to airway compromise with obstruction, trismus, dysphagia, and severe pain. Aspiration under local anesthetic may be possible, but extensive surgery may need to be done under general anesthesia For patients without airway compromise, an intravenous induction with careful laryngoscopy and tracheal intubation, avoiding rupture of the abscess, can be done

If airway compromise or anatomic distortion is present, an awake fiberoptic nasotracheal intubation technique

If airway compromise or anatomic distortion is present, an awake fiberoptic nasotracheal intubation technique or tracheostomy under local anesthetic indicated.

Tongue Base and Supraglottic Lesions Even small lesions can have significant effect on the

Tongue Base and Supraglottic Lesions Even small lesions can have significant effect on the airway Danger from IV induction is loss of supportive tone. An oral or nasal airway may be ineffective in relieving the obstruction A strong jaw thrust maneuver may be required

Standard curved blade laryngoscopy can traumatize any lesion at the tongue base and valleculae

Standard curved blade laryngoscopy can traumatize any lesion at the tongue base and valleculae Straight blade may also be ineffective in distorted epiglottis In pts with suspected supraglottic airway compromiseawake fiberoptic intubation awake transtracheal catheter awake laryngeal block with direct laryngoscopy an awake local anesthetic tracheostomy

 Glottic Lesions Laryngeal pathology with T 1, T 2 lesions can be managed

Glottic Lesions Laryngeal pathology with T 1, T 2 lesions can be managed with conventional airway management techniques. IV induction with cuffed ET tube “ tracheostomy tube Supraglottic and subglottic jet ventilation for biopsy

Options limited in advanced lesions or airway compromise Awake fiberoptic intubation techniques have an

Options limited in advanced lesions or airway compromise Awake fiberoptic intubation techniques have an associated morbidity and mortality Inhaled induction for advanced laryngeal tumors with airway obstruction is difficult and challenging Induction is slow with apneic periods, and episodes of obstruction are common.

The administration of a muscle relaxant provides optimal ventilation and intubating conditions At a

The administration of a muscle relaxant provides optimal ventilation and intubating conditions At a suitable depth of anesthesia, laryngoscopy is undertaken Smaller sized ET tubes must be ready A gum elastic bougie or stylet may be useful. Failure to intubate requires an urgent tracheostomy, and the surgeon should be gowned and immediately ready.

Transtracheal catheter placement Under local anesthesia Catheter is placed usually at the level of

Transtracheal catheter placement Under local anesthesia Catheter is placed usually at the level of the second or third tracheal rings, avoiding the tumor and the risk of bleeding and tumor seeding. Intravenous induction is started Jet ventilation through the transtracheal catheter is begun