Mod9: Nasal and Sinus Surgery - Ear Surgery - Head and Neck Cancer Surgery - Maxillofacial Reconstruction Flashcards
Otolaryngologic Surgery
Nasal and Sinus Surgery
Preoperative considerations
Nasal obstruction → face mask ventilation difficult
Nasal polyps → allergic disorders/asthma/cystic fibrosis
Nasal mucosa richly vascular → review history for bleeding problems/ASA ingestion (consider PT/PTT)
Otolaryngologic Surgery
Nasal and Sinus Surgery
Technique
Local with sedation vs. General
Otolaryngologic Surgery
Nasal and Sinus Surgery
Considerations with local anesthesia
Lidocaine/Cocaine (4-10%)
Toxic levels?
Vasoconstrictors (epinephrine/phenylephrine)
Shrink mucosa
Decreased bleeding
BP?
Otolaryngologic Surgery
Nasal and Sinus Surgery
Intraoperative considerations
Reinforced/oral RAE tube
Arms tucked
Bed turned 90-180˚
Protect eyes (tape/lube)**
Throat pack!
NDMR “Strongly” suggested
(Neurological/ophthalmological damage)
Nasal and Sinus Surgery - Intraoperative considerations
Protect eyes (tape/lube)**
Exception is with
Functional Endoscopic Sinus Surgery (FESS)
Surgeon checks eye movement
Nasal and Sinus Surgery - Intraoperative considerations
NDMR “Strongly” suggested
Why?
Presence of rigid scope in the nose
Sudden motion could cause:
=> Serious Neurological/ophthalmological damage
Otolaryngologic Surgery - Nasal and Sinus Surgery
Techniques to minimize blood loss/improve surgical field visualization
Supplementation with vasoconstrictors (cocaine/phenylephrine/oxymetazoline=Afrin)
HOB elevated
Controlled hypotension (SBP<100 mmHg)
(Use MAP - Stay within 20% of Pt’s baseline)
Otolaryngologic Surgery - Nasal and Sinus Surgery
Emergence
“SMOOTH” with minimal coughing/bucking
↑ venous pressure → ↑ bleeding
Deep extubation
Must weigh this against the <u>Risk for aspiration</u> and for
a potential <u>Laryngospasm</u>!
Nasal and Sinus Surgery - Emergence
Deep extubation
Must be weighed against:
Risk aspiration
Laryngospasm!
(Risk of Laryngospam greatly increased during stage II anesthesia)
Otolaryngologic Surgery
Ear Surgery
Procedures:
Tympanoplasty/mastoidectomy
Myringotomy & tubes
Otolaryngologic Surgery - Ear Surgery
N20?
Go or No go?
Middle ear is a “air-filled, nondistendible space”
More soluble then N2
→ diffusion into air-containing cavity
→ ↑ pressure
Avoid or discontinue just prior to tympanic membrane graft placement (tympanoplasty)
Otolaryngologic Surgery - Ear Surgery
Muscle relaxation with NDMR?
Go or No go?
Facial nerve monitoring with mastoidectomy
Avoid b/c will interfere with monitoring
Discuss with surgical team
Otolaryngologic Surgery - Ear Surgery
Hemostasis critical
why?
Microsurgical procedure
(They are working in a very small space)
Small amounts blood obscure surgical field
Elevate HOB
Topical application epinephrine (1:50,000-200,000)
Controlled hypotensive technique
Otolaryngologic Surgery - Ear Surgery
Smooth emergence again critical
Why?
Dislodgement graft
Prevent/Avoid coughing and “bucking”
Otolaryngologic Surgery - Ear Surgery
PONV
Considerations:
High incidence PONV
Attenuate with:
Decadron/Zofran/TIVA
Otolaryngologic Surgery - Ear Surgery
Positioning
Head rotated laterally
=> Avoid extreme tension (Brachial/Cervical plexus injury)
=> Caution<u> C1-C2 subluxation </u>in peds/RA/<strong>Down syndrome</strong>
Table turned 180˚ with arms tucked
BP placed on nonoperative side!
Otolaryngologic Surgery
Head and Neck Cancer Surgery
Different procedures:
Laryngectomy
Glossectomy
Pharyngectomy
Mandibulectomy
Radical neck dissection
I&D abscess (Ludwig’s Angina)
Otolaryngologic Surgery
Head and Neck Cancer Surgery
Sample post-op picture:
Sample post-op picture