Extracranial Surgery

Question 1

Why would a parotidectomy be performed?

Answer 1

A parotidectomy may be performed for infection of the gland or
for parotid tumor removal.
Jaffe RA, Schmiesing CA, Golianu B. Anesthesiologist’s
Manual of Surgical Procedures. 5th ed. Philadelphia, PA:
Wolters Kluwer Health, 2014: 224.

Question 2

What is the difference between a total parotidectomy

and a radical parotidectomy?

Answer 2

A total parotidectomy spares the facial nerve, while a radical
parotidectomy removes the facial nerve along with the parotid
gland.
Jaffe RA, Schmiesing CA, Golianu B. Anesthesiologist’s
Manual of Surgical Procedures. 5th ed. Philadelphia, PA:
Wolters Kluwer Health, 2014: 224-225.

Question 3

What is the etiology of parotid tumors?

Answer 3

75% of the tumors are benign pleomorphic adenomas. The
remainder are either malignant tumors or result from chronic
sialoadenitis.
Jaffe RA, Schmiesing CA, Golianu B. Anesthesiologist’s
Manual of Surgical Procedures. 5th ed. Philadelphia, PA:
Wolters Kluwer Health, 2014: 226.

Question 4

How is the patient positioned for a parotidectomy?

Answer 4

The patient is positioned supine with the head turned slightly
towards the opposite side.
Jaffe RA, Schmiesing CA, Golianu B. Anesthesiologist’s
Manual of Surgical Procedures. 5th ed. Philadelphia, PA:
Wolters Kluwer Health, 2014: 225.

Question 5

How should the endotracheal tube be positioned for

a parotidectomy?

Answer 5

The endotracheal tube should be taped to the opposite side of
the mouth from the surgical site.
Jaffe RA, Schmiesing CA, Golianu B. Anesthesiologist’s
Manual of Surgical Procedures. 5th ed. Philadelphia, PA:
Wolters Kluwer Health, 2014: 225.

Question 6

Is surgical paralysis necessary for patients

undergoing parotidectomy?

Answer 6

No. Because the facial nerve has branches that invest the
parotid gland and nerve monitoring is employed to protect the
nerve, muscle relaxation is contraindicated in this procedure.
Jaffe RA, Schmiesing CA, Golianu B. Anesthesiologist’s
Manual of Surgical Procedures. 5th ed. Philadelphia, PA:
Wolters Kluwer Health, 2014: 225.

Question 7

For what reasons are enucleations performed?

Answer 7

An enucleation is the removal of the entire eye and a portion of
the optic nerve. It is performed for intraocular tumors or painful
blind eyes.
Jaffe RA, Schmiesing CA, Golianu B. Anesthesiologist’s
Manual of Surgical Procedures. 5th ed. Philadelphia, PA:
Wolters Kluwer Health, 2014: 168.

Question 8

Many clinicians have atropine on hand during an

enucleation. Why is this?

Answer 8

During an enucleation procedure, the oculocardiac reflex may
be stimulated during dissection of the ocular muscles resulting
in bradycardia and/or asystole requiring the administration of
atropine intravenously.
Jaffe RA, Schmiesing CA, Golianu B. Anesthesiologist’s
Manual of Surgical Procedures. 5th ed. Philadelphia, PA:
Wolters Kluwer Health, 2014: 176.

Question 9

What anesthetic technique is recommended for an

enucleation.

Answer 9

General endotracheal anesthesia is recommended. The high
incidence of postoperative nausea and vomiting also
necessitates the use of antiemetics.
Jaffe RA, Samuels SI. Anesthesiologist’s Manual of Surgical
Procedures. 4th ed. Philadelphia, PA: Lippincott Williams and
Wilkins, 2009: 162-164.

Question 10

Is deep extubation contraindicated on emergence

from an enucleation?

Answer 10

No, because bucking and coughing on emergence can result in
venous congestion and postoperative bleeding, deep extubation
or administration of fentanyl and/or lidocaine should be
considered.
Jaffe RA, Schmiesing CA, Golianu B. Anesthesiologist’s
Manual of Surgical Procedures. 5th ed. Philadelphia, PA:
Wolters Kluwer Health, 2014: 174-175.

Question 11

During opthalmic surgery, the surgeon requests that
you administer mannitol. Why would he request this
and how would you administer it?

Answer 11

The administration of mannitol may be used to decrease
intraocular pressure intraoperatively. The total dose should not
exceed 1.5-2 grams/kg over a 30-60 minute period.
Jaffe RA, Schmiesing CA, Golianu B. Anesthesiologist’s
Manual of Surgical Procedures. 5th ed. Philadelphia, PA:
Wolters Kluwer Health, 2014: 175.

Question 12

A patient presenting for opthalmic surgery is taking
acetazolamide. Why would this patient be taking this
drug and what electrolyte abnormalities may be
present?

Answer 12

Acetazolamide is a carbonic anhydrase inhibitor that may be
used to treat increased intraocular pressure. Because it also
inhibits carbonic anhydrase in the kidneys, patients taking this
on a chronic basis may exhibit acidosis, hypokalemia, and
hyponatremia.
Jaffe RA, Schmiesing CA, Golianu B. Anesthesiologist’s
Manual of Surgical Procedures. 5th ed. Philadelphia, PA:
Wolters Kluwer Health, 2014: 175.

Question 13

What other conditions should you evaluate for
preoperatively in a patient presenting for strabismus
surgery?

Answer 13

Strabismus surgery is the most common pediatric ocular
surgery and may be an indicator that there is underlying disease
as it is associated with a high incidence of prematurity, cerebral
palsy, and craniofacial abnormalities. Strabismus surgery is
also associated with a higher than normal incidence of
malignant hyperthermia.
Jaffe RA, Schmiesing CA, Golianu B. Anesthesiologist’s
Manual of Surgical Procedures. 5th ed. Philadelphia, PA:
Wolters Kluwer Health, 2014: 1199.

Question 14

Why should hypercapnia be avoided in a patient

undergoing strabismus surgery?

Answer 14

Hypercapnia increases the risk of bradycardia due to the
oculocardiac reflex which can occur due to traction on the
ocular muscles.
Jaffe RA, Schmiesing CA, Golianu B. Anesthesiologist’s
Manual of Surgical Procedures. 5th ed. Philadelphia, PA:
Wolters Kluwer Health, 2014: 1199.

Question 15

What is the incidence of postoperative nausea and

vomiting in patients undergoing strabismus surgery?

Answer 15

The incidence of postoperative nausea and vomiting is as high
as 85% in this patient class.
Jaffe RA, Schmiesing CA, Golianu B. Anesthesiologist’s
Manual of Surgical Procedures. 5th ed. Philadelphia, PA:
Wolters Kluwer Health, 2014: 1199.

Question 16

What precautions should you take during the
anesthetic for a patient presenting for repair of an
open-globe eye injury?

Answer 16

Deep extubation is recommended in this class of patient to
decrease the risk of coughing and injuring the newly repaired
eye. Succinylcholine can increase intraocular pressure and
should be avoided in this patient. Retrobulbar and peribulbar
blocks can increase the pressure exerted against the eye and
increase the risk for extrusion of ocular contents in an open
globe injury.
Butterworth JF, Mackey DC, Wasnick JD. Morgan & Mikhail’s
Clinical Anesthesiology. 5th ed. New York, NY: McGraw-Hill;
2013: 768.

Question 17

Blockade of which nerve would prevent a patient
from squinting during placement of a lid speculum for
opthalmologic procedures?

Answer 17

Blockade of the facial nerve will prevent the patient from being
able to squint the eyelids and allow placement of a lid speculum.
Butterworth JF, Mackey DC, Wasnick JD. Morgan & Mikhail’s
Clinical Anesthesiology. 5th ed. New York, NY: McGraw-Hill;
2013: 767.

Question 18

Why should nitrous oxide be avoided in patients

undergoing repair of a detached retina?

Answer 18

Opthalmologists may inject expanding gases such as sulfur
hexafluoride or perfluoropropane into the eye to press a torn
retina back into place. The use of nitrous oxide can cause the
injected bubble to expand rapidly, causing a dramatic increase
in intraocular pressure and possibly interrupting retinal blood
flow. Nitrous oxide is often avoided in these surgeries, but if
used, it should be discontinued at least 15 minutes before an
expanding gas is injected. If a patient is presenting for a
second surgery, nitrous oxide should be avoided for up to 10
days after an air injection, 30 days after the injection of sulfur
hexafluoride and 90 days after the injection of C3F8.
Jaffe RA, Schmiesing CA, Golianu B. Anesthesiologist’s
Manual of Surgical Procedures. 5th ed. Philadelphia, PA:
Wolters Kluwer Health, 2014: 175.

Question 19

During general anesthesia for endoscopic surgery of
the ethmoid sinus, the surgeon indicates he may
have pierced the ethmoid roof. What are the
anesthesia implications you should consider on
emergence?

Answer 19

The roof of the ethmoid sinus is the cribriform plate and anterior
skull base. Piercing this sinus can result in a communication
between the airway and the cranial vault and cerebrospinal fluid
may be seen leaking from the nose. Bag-mask ventilation is to
be avoided in any patients with a known skull base defect as it
could result in pneumocephalus.
Jaffe RA, Schmiesing CA, Golianu B. Anesthesiologist’s
Manual of Surgical Procedures. 5th ed. Philadelphia, PA:
Wolters Kluwer Health, 2014: 230.

Question 20

Why should nitrous oxide be avoided in patients

undergoing repair of a a tympanoplasty?

Answer 20

Because nitrous oxide is more soluble than nitrogen, it can
diffuse into an air-filled cavity faster than nitrogen can diffuse
out or be absorbed into the blood. As a result, once the graft is
placed, the inner ear becomes a closed space. The
accumulation of pressure in the middle ear due to the diffusion
of nitrous oxide into it can displace the graft. Because of the
high incidence of postoperative nausea and vomiting associated
with these cases, drugs used to prevent nausea such as 5-HT3
blockers, decadron, and even droperidol are commonly
employed.
Butterworth JF, Mackey DC, Wasnick JD. Morgan & Mikhail’s
Clinical Anesthesiology. 5th ed. New York, NY: McGraw-Hill;
2013: 784.