Mod9: Nasal and Sinus Surgery - Ear Surgery - Head and Neck Cancer Surgery - Maxillofacial Reconstruction

Question 1

_{Otolaryngologic Surgery}

Nasal and Sinus Surgery

^{Preoperative considerations}

Answer 1

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)

Question 2

_{Otolaryngologic Surgery}

Nasal and Sinus Surgery

^Technique

Answer 2

Local with sedation vs. General

Question 3

_{Otolaryngologic Surgery}

Nasal and Sinus Surgery

^{Considerations with local anesthesia}

Answer 3

Lidocaine/Cocaine (4-10%)

^{Toxic levels?}

Vasoconstrictors (epinephrine/phenylephrine)

^{Shrink mucosa}

^{Decreased bleeding}

^BP?

Question 4

_{Otolaryngologic Surgery}

Nasal and Sinus Surgery

^{Intraoperative considerations}

Answer 4

Reinforced/oral RAE tube

Arms tucked

Bed turned 90-180˚

Protect eyes (tape/lube)**

Throat pack!

NDMR “Strongly” suggested

^{(Neurological/ophthalmological damage)}

Question 5

_{Nasal and Sinus Surgery - Intraoperative considerations}

Protect eyes (tape/lube)**

^{Exception is with}

Answer 5

Functional Endoscopic Sinus Surgery (FESS)

Surgeon checks eye movement

Question 6

_{Nasal and Sinus Surgery - Intraoperative considerations}

NDMR “Strongly” suggested

^Why?

Answer 6

Presence of rigid scope in the nose

Sudden motion could cause:

=> Serious Neurological/ophthalmological damage

Question 7

_{Otolaryngologic Surgery - Nasal and Sinus Surgery}

Techniques to minimize blood loss/improve surgical field visualization

Answer 7

Supplementation with vasoconstrictors ^{(cocaine/phenylephrine/oxymetazoline=Afrin)}

HOB elevated

Controlled hypotension (SBP<100 mmHg)

^{(Use MAP - Stay within 20% of Pt’s baseline)}

Question 8

_{Otolaryngologic Surgery - Nasal and Sinus Surgery}

Emergence

Answer 8

“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>!}

Question 9

_{Nasal and Sinus Surgery - Emergence}

Deep extubation

^{Must be weighed against:}

Answer 9

Risk aspiration

Laryngospasm!

^{(Risk of Laryngospam greatly increased during stage II anesthesia)}

Question 10

_{Otolaryngologic Surgery}

Ear Surgery

^Procedures:

Answer 10

Tympanoplasty/mastoidectomy

Myringotomy & tubes

Question 11

_{Otolaryngologic Surgery - Ear Surgery}

N₂0?

^{Go or No go?}

Answer 11

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)

Question 12

_{Otolaryngologic Surgery - Ear Surgery}

Muscle relaxation with NDMR?

^{Go or No go?}

Answer 12

Facial nerve monitoring with mastoidectomy

Avoid b/c will interfere with monitoring

Discuss with surgical team

Question 13

_{Otolaryngologic Surgery - Ear Surgery}

Hemostasis critical

^why?

Answer 13

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

Question 14

_{Otolaryngologic Surgery - Ear Surgery}

Smooth emergence again critical

^Why?

Answer 14

Dislodgement graft

Prevent/Avoid coughing and “bucking”

Question 15

_{Otolaryngologic Surgery - Ear Surgery}

PONV

^{Considerations:}

Answer 15

High incidence PONV

Attenuate with:

Decadron/Zofran/TIVA

Question 16

_{Otolaryngologic Surgery - Ear Surgery}

Positioning

Answer 16

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!

Question 17

_{Otolaryngologic Surgery}

Head and Neck Cancer Surgery

^{Different procedures:}

Answer 17

Laryngectomy

Glossectomy

Pharyngectomy

Mandibulectomy

Radical neck dissection

I&D abscess (Ludwig’s Angina)

Question 18

_{Otolaryngologic Surgery}

Head and Neck Cancer Surgery

^{Sample post-op picture:}

Answer 18

Sample post-op picture

Question 19

_{Head and Neck Cancer Surgery - Preoperative Considerations}

Patient population

Answer 19

Elderly

Pre-existing medical conditions

^{COPD, CAD, Chronic tobacco/ETOH abuse, malnutrition}

Question 20

_{Head and Neck Cancer Surgery - Preoperative Considerations}

Airway management

^{Abnormal airway anatomy (lesion/tumor/infection/radiation therapy) →}

Answer 20

potential airway compromise/problems

Question 21

_{Head and Neck Cancer Surgery - Preoperative Considerations}

Airway management

^{when in DOUBT!!}

Answer 21

Awake FOI (cooperative)

Inhalation induction (uncooperative) maintaining spontaneous ventilation

Awake tracheostomy

Surgeon should be immediately available for emergency tracheostomy during induction

Do NOT perform Induction without the surgical provider being present and scrubed in!!!

Question 22

_{Otolaryngologic Surgery​ - Head and Neck Cancer Surgery}

Intraoperative Considerations

Answer 22

Long procedures

^{Positioning - Hypothermia}

Potential for large blood loss

^{(rapid vs. slow oozing)}

Cardiovascular instability

^{(carotid sinus manipulation)}

Question 23

_{Head and Neck Cancer Surgery - Intraoperative Considerations}

Monitoring

Answer 23

2 large bore PIV with blood tubing

Aline

Central line

^{(Antecubital - Femoral)}

Foley

Fluid warmers/bair huggers

Question 24

_{Head and Neck Cancer Surgery - Intraoperative Considerations}

NDMR mostly avoided

^why?

Answer 24

Nerve monitoring

Question 25

_{Head and Neck Cancer Surgery - Intraoperative Considerations} **Hypotensive technique** ^{may be requested by surgical Team to Decrease blood loss if no contraindications. However you must be cautious with:}

Answer 25

CPP compromised by carotid/jugular tumor Cerebral vascular disease CAD

Question 26

_{Head and Neck Cancer Surgery - Intraoperative Considerations} **Request to Not administer too much volume** ^why?

Answer 26

Too much volume keeps the graft from healing properly

Question 27

_{Head and Neck Cancer Surgery - Intraoperative Considerations} **HOB elevated** ^why?

Answer 27

There is an ↑ risk of VAE otherwise

Question 28

_{Head and Neck Cancer Surgery - Intraoperative Considerations} ## Footnote **Microvascular free flap**

Answer 28

**Avoid vasoconstrictors** ^{SBP increase however, flap perfusion decreases} **Caution use of vasodilators** ^{Decrease perfusion pressures} **Maintain BP at baseline**

Question 29

_{Head and Neck Cancer Surgery - Intraoperative Considerations} ## Footnote **Blood transfusions?**

Answer 29

Balance risk of post-transfusion cancer reoccurrence _Low HCT (27-30%)_ actually **desirable** for microvascular free flaps

Question 30

_{Head and Neck Cancer Surgery - Intraoperative Considerations} CV instability with carotid sinus/stellate ganglion manipulation (R\>L)

Answer 30

Bradycardia, arrhythmia, sinus arrest “Wide” swings BP Infiltration of with LA ameliorates Bilateral Neck Dissection ^{(Postoperative HTN - Loss hypoxic drive)}

Question 31

_{Head and Neck Cancer Surgery - Intraoperative Considerations} **Intraoperative tracheostomy** ^Procedure:

Answer 31

Administer 100% O2 just prior to placement Deflate cuff to avoid perforation once dissection complete **Withdraw** ETT (**slowly**) to just cephalad to incision Sterile wired/reinforced ETT place into trachea and sutured in by surgeon Assess Bilateral Breath Sounds/ETCO2/Peak Insp Pressure Remove old ETT

Question 32

_{Head and Neck Cancer Surgery - Intraoperative Considerations} **Intraoperative tracheostomy** ^{why is it done intra-op and not at the begining of the case?}

Answer 32

**For these big head and neck procedures** Pts are intubated as normal Bed is turned Surgical airway is obtained Then the actual surgery is started

Question 33

_{Otolaryngologic Surgery} **Maxillofacial Reconstruction** ^{could be as a result of:}

Answer 33

**Trauma** ^{(LeFort fractures)} Malformations Radical cancer surgery **Orthogenic** ^{(LeFort osteotomy, mandibular osteotomy)}

Question 34

_{Otolaryngologic Surgery} **Maxillofacial Reconstruction** ^{Main challenge:}

Answer 34

Securing airway due to unknown anatomic alterations

Question 35

_{Otolaryngologic Surgery - Maxillofacial Reconstruction} **LeFort I fracture** ^Review:

Answer 35

(see picture)

Question 36

_{Otolaryngologic Surgery - Maxillofacial Reconstruction} **LeFort II fracture** ^Review:

Answer 36

(see picture)

Question 37

_{Otolaryngologic Surgery - Maxillofacial Reconstruction} **LeFort III fracture** ^Review:

Answer 37

(see picture) **L**eFort III fracture is the **most detrimental!!!**

Question 38

_{Otolaryngologic Surgery - Maxillofacial Reconstruction} ## Footnote **LeFort fractures**

Answer 38

LeFort **II** & **III** may be associated with **basilar skull fractures** LeFort **III** may involve **separation of nasopharynx and skull** (basilar skull fracture/CSF rhinorrhea) Airway management becomes challenge

Question 39

_{Maxillofacial Reconstruction - LeFort fractures} ## Footnote **Airway management becomes challenge**

Answer 39

**Nasotracheal intubation contraindication** ^{Could cause Meningitis, Direct mechanical damage brain} **Avoid PPV** ^{Force air/foreign material into skull} Obviated by performing **awake tracheostomy** in patients with known or **suspected LeFort III** with basilar skull fracture

Question 40

_{Otolaryngologic Surgery - Maxillofacial Reconstruction} **Trismus** ^{what is it?}

Answer 40

**Spasm of masseter** muscles impairs **jaw relaxation** _{Usually relax in response to anesthesia and muscle relaxants Prolonged condition → masseter fibrosis!!!}

Question 41

_{Otolaryngologic Surgery - Maxillofacial Reconstruction} **Ludwig's Angina** ^{What is it?}

Answer 41

**Septic cellulitis of submandibular region** **_D/t:** Dental infection (extraction 2nd & 3rd molars)

Question 42

_{Otolaryngologic Surgery - Maxillofacial Reconstruction} **Ludwig's Angina** ^{manifestations:}

Answer 42

Soft tissue edema → upward & posterior displacemnet of tongue Frequent presence of laryngeal edema Upper airway obstruction

Question 43

_{Otolaryngologic Surgery - Maxillofacial Reconstruction} **Ludwig's Angina** ^{managed as:}

Answer 43

Airway emergency AFOI is a must

Question 44

_{Otolaryngologic Surgery - Maxillofacial Reconstruction} **Securing the airway** ^{How achived in patient with upper airway obstruction/tumor/infection:}

Answer 44

AFOI/Tracheostomy

Question 45

_{Maxillofacial Reconstruction - Securing the airway} **Awake look?** ^{when indicated?}

Answer 45

Prior to induction and administration muscle relaxant

Question 46

_{Maxillofacial Reconstruction - Securing the airway} **Awake look?** ^{Could be Misleading - How so?}

Answer 46

Skeletal muscle tone present when awake but absent once anesthetized

Question 47

_{Maxillofacial Reconstruction - Securing the airway} **Maxillofacial Trauma** ^{considerations:}

Answer 47

Ability to **open mouth limited** to pain, trismus, edema, mechanical (dilocation/TMJ) Pain will not influence **mouth opening** when **anesthetized**/paralyzed (MRSI) Others, consider **AFOI/Tracheostomy**