DR ABDOLLAHI

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Surgical procedures involving the eyes, ears, nose, and
throat require a cooperative relationship between the
surgeon and the anesthesiologist. It is important for the
anesthesiologist to appreciate the anatomy and physiology
of the structures in the operative field.

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In addition, an understanding of the surgical procedure is
important.
Patients undergoing surgical procedures on the , head,
and neck represent a diversity of age groups from infants
to the elderly.

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It is important to appreciate that manipulation of the larynx,
pharynx, and neck may precipitate cardiac dysrhythmias
and that blood loss can be underestimated as a result of
hidden losses within the surgical drapes and blood
swallowed into the stomach.

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The use of neuromonitoring techniques during surgery to
aid the surgeon in identification of peripheral nerves in
the operative area may influence the choice and dose of
anesthetic and neuromuscular blocking drugs.

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Damage to nerves that innervate the pharynx, larynx, and
especially the vocal cords (may be manifested promptly
after tracheal extubation) can occur during head and neck
surgery. The presence of laryngeal and pharyngeal edema
should be considered before tracheal extubation.

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Most patients scheduled for head and neck surgery will
have their airway examined by the surgeon before surgery.
The anesthesiologist should communicate with the
surgeon about the probability of a difficult airway and
whether nasal or oral tracheal intubation is indicated for
optimal surgical exposure.

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An awake fiberoptic intubation of the trachea
or a tracheostomy under local anesthesia may be
indicated if difficult upper airway management is
anticipated.
The anesthesiologist should be familiar with the variety
of endotracheal tubes that are available for head and neck
surgery to facilitate better surgical exposure

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Instrumentation or manipulation of the endolarynx or
the presence of blood or a foreign body can induce
laryngospasm.
Laryngospasm is an exaggerated and prolonged
response of the protective glottic closure reflex, mediated
by the superior laryngeal nerve. “With severe Laryngospasm,
the false cords and epiglottic body come together firmly.
Airflow is absent, there is no vocal sound, and the true
vocal cords cannot be seen.

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If laryngospasm persists, arterial hypoxemia and
hypercapnia will decrease postsynaptic action potentials
and brainstem output to the superior laryngeal nerve,
and the intensity of the laryngospasm will eventually
decrease.

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The most common method of overcoming laryngospasm is
continued positive airway pressure applied by faccmask
or the intravenous administration of a neuromuscular
blocking drug such as succinylcholine(0.25 to 1 mg/kg).
Intubation of the trachca may be warranted in selected
patients.

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Patients who undergo tonsillectomy and adenoidectomy
are usually young and healthy. Although recurrent upper
respiratory tract infection remains a significant indication
for surgery, upper airway obstruction, especially during
sleep (obstructive sleep apnea [OSA]), accounts for an
increasing percentage of the procedures performed,
especially in children younger than 4 years.

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Preoperative evaluation for tonsillectomy or
adenoidectomy, or both, depends on the initial history
and physical examination. In otherwise normal patients
who have classic symptoms of severe upper airway
obstruction and adenotonsillar hypertrophy, the
preoperative evaluation rarely requires any special
studies.

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In some patients, if severe airway obstruction is
suspected, an electrocardiogram, echocardiogram, chest
radiograph, and coagulation studies may be considered.
Sedative premedication may be avoided in children with
OSA, intermittent upper airway obstruction, or very large
tonsils.

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OSA syndrome may be associated with behavior and
growth disturbances. Symptoms in these patients include
snoring, sleep disturbances and daytime hypersomnolence,
decreased school performance and personality changes, recurrent
enuresis, hyponasal speech, and growth disturbances.
Patients with OSA are often obese with potentially difficult upper
airway management.

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These individuals will probably have short, thick necks,
large tongues, and redundant pharyngeal tissues such
that upper airway obstruction is frequent and awake
tracheal intubation will be necessary. Polysomnography
to evaluate the severity of OSA requires hospitalization,
is expensive, and is rarely needed.

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Patients may arrive at the hospital for elective
tonsillectomy and adenoidectomy with an acute upper
respiratory tract infection. Surgery for these patients is
usually postponed until resolution of the upper
respiratory tract infection, which is typically 7 to 14 days.
Laryngospasm with airway manipulation may be more
likely to occur in the presence of an upper respiratory
tract infection.

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Gastroesophageal reflux disease (GERD) may be a
significant symptom in children with chronic lung disease
or upper airway obstruction (or both) secondary to
increased intrathoracic negative pressure. This is
particularly relevant in neurologically abnormal patients
(hypotonia, developmental delay) because such patients
have a high incidence of GERD even without upper
airway obstruction.

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GERD is a consideration in young children with
significant developmental delay who require tonsillectomy
to treat upper airway obstruction.

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Management of anesthesia for patients undergoing
tonsillectomy is focused on airway considerations and
bleeding. Continuous positive airway pressure during
induction of anesthesia may be useful for alleviating
upper airway obstruction.

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Placement of a cuffed endotracheal tube will decrease the
incidence of aspiration of blood. As with an uncuffed
tube, a cuffed endotracheal tube should be appropriately
sized to allow an air leak around the tube with 20 to 25
cm H20 of peak airway pressure.

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The tracheal tube cuff is inflated beyond this point only if
high peak airway pressure is needed to ventilate the
lungs adequately or if hemorrhage suddenly develops.

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When difficult tracheal intubation is anticipated, it
may be helpful to have an otolaryngologist present. The
use of an oral RAE tube for tracheal intubation may
optimize visualization of the surgical field.

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The supraglottic area may be packed with petroleum
gauze to minimize the likelihood of inhalation of blood
from the pharynx.
when gauze packing is used, it is important to maintain
an appropriate leak around the tube during the application
of positive airway pressure.

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The practice of monitoring young children for 24 hours
after surgery is based on observations of postoperative
airway obstruction occurring in children younger than 4
years as late as 18 to 24 hours postoperatively.
In addition to young age, risk factors associated with
postoperative airway obstruction after tonsillectomy may
include prematurity and recent upper respiratory
infection.

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Surgeons are meticulous about ensuring a dry tonsillar
bed at the end of surgery and often place a pack in the
posterior of the pharynx to limit draining of blood into the
stomach during the procedure. Inserting an orogastric
tube into the stomach before extubating the trachea while
being careful to not traumatize the adenoidectomy site is
a frequent maneuver to remove any blood that may have
drained into the stomach.

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Tracheal extubation is performed when the child is awake
and responding. In patients with reactive airway disease,
including asthma, tracheal extubation may be performed
while the patient is still anesthetized to decrease the
likelihood of bronchospasm and laryngospasm.

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Dexamethasone administered intravenously may be
useful for decreasing postoperative pain. Adding an
intraoperative dose of an antiemetic and removing blood
from the stomach may combine to decrease postoperative
emesis.

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Hemorrhage from a bleeding tonsil in the postoperative
period is a recognized complication. The need for tracheal
reintubation may be complicated by the presence of large
amounts of swallowed blood in the stomach. In this regard,
care should be taken to not oversedate these patients. If
the bleeding is not controlled, the patient should be
returned to the operating room for exploration and
surgical hemostasis.

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Acute airway obstruction such as laryngospasm can
lead to negative-pressure pulmonary edema. This occurs
as the patient breathes against a closed glottis and
negative intrathoracic pressure is created. This pressure
is transmitted to interstitial tissue, where the hydrostatic
pressure gradient is increased and enhances fluid
movement out of the pulmonary circulation into the
alveoli. Airway obstruction in the postoperative period
can also be associated with retention of a pharyngeal
pack.

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• Emesis (occurs in 30%–65% of patients; mechanism unknown but
may include the presence of irritant blood in the stomach)
• Dehydration
• Hemorrhage (75% occurs in first 6 hours after surgery; if surgical
hemostasis is required, a full stomach and hypovolemia should be
considered)
• Pain (minimal after adenoidectomy and severe after tonsillectomy)
• Postobstructive pulmonary edema (rare but possible if the patient
has had a prior acute upper airway obstruction; treatment may
include supplemental oxygen and administration of diuretics)

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Examples of patients in whom early discharge is not
advised after tonsillectomy include those younger than 3
years of age and those with abnormal coagulation
values, evidence of obstructive sleep disorder or apnea,
presence of a peritonsillar abscess, and conditions
(distance, weather, social conditions) that would prevent
close observation or prompt return to the hospital.

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Laser surgery provides precision in targeting airway
lesions, minimal bleeding and edema, preservation of
surrounding structures, and rapid healing. The carbon
dioxide laser has particular application in the treatment
of laryngeal or vocal cord papillomas, laryngeal webs,
resection of redundant subglottic tissue, and coagulation
of hemangiomas.

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In most cases laser surgery is preceded by microdirect
laryngoscopy. The use of small-diameter
endotracheal tubes (5.0 or 5.5 mm internal diameter) is
necessary for optimum exposure. Brief skeletal muscle
paralysis as provided by an infusion of succinylcholine
may be useful.

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Anesthesia during laser surgery may be administered with
or without an endotracheal tube. However, appropriate
laser-resistant endotracheal tubes should be available. In
this regard, all polyvinyl chloride endotracheal tubes are
flammable and can ignite and vaporize when in contact
with the laser beam.

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Some surgeons may prefer using a Dedo or Marshall laryngoscope
and intermittent ventilation with a Sanders jet ventilator. The
Sanders jet ventilator delivers oxygen at 50 psi directly through a
port in the laryngoscope. If a Dedo or Marshall laryngoscope is
used, maintenance anesthesia can be accomplished with an
intravenous anesthetic.

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Use of the Sanders jet ventilator is associated with a risk
for pneumothorax and pneumomediastinum as a result
of rupture of alveolar blebs or a bronchus.

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Laser surgery produces a plume of smoke and particles
(mean size, 0.31µm) that can be deposited in the
alveoli if aspirated . This hazard can be minimized if an
efficient smoke evacuator and special masks are used. A
misdirected laser bean can also lead to perforation of a
viscus and transection of blood vessels.
Other risks include venous gas embolism and ocular
injury.

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The patient's eyes must be protected by taping
them shut, followed by the application of wet gauze pads
and a metal shield to prevent laser penetration. All
operating room personnel should wear special protective
glasses.

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 Characteristic signs and symptoms of acute epiglottitis
include
(1) a sudden onset of fever, dysphagia, drooling, thick
muffled voice, and preference for the sitting position
with the head extended and leaning forward
(2) retractions, labored breathing, and cyanosis when
respiratory obstruction is present.

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