Anesthesia for the Otolaryngologist

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Anesthesia for the Otolaryngologist

Clinical Fundamentals
Author Credentials 

Cecelia E. Schmalbach, MD, MSc
Professor and Vice Chairman, Clinical Affairs
Otolaryngology-Head & Neck Surgery
Indiana University School of Medicine
Indianapolis, IN

Module Summary

Otolaryngologists are viewed as the airway expert, partnering closely with our anesthesia colleagues and managing complex airway emergencies. This module covers the breadth of anesthesia related topics encountered in otolaryngology, from local anesthesia and conscious sedation to general anesthesia and emergency surgical airway management. Emphasis is placed on pharmacokinetics, patient selection and contraindications. Complications related to general anesthesia are highlighted to include malignant hyperthermia will be included.
 

Local Anesthetic

Learning Objectives:

  1. List commonly used aminoester and aminoamide local anesthetics used in head and neck surgery.
  2. Understand the mechanism of action, metabolism, dosage, and excretion of the aminoester and aminoamide local anesthetics.
  3. Recognize signs of systemic toxicity.
  4. Describe indications, anatomy of the trigeminal nerve, and technique for head and neck regional blocks using local anesthesia.
    • Scalp block: supraorbital nerve; supratrochlear nerve; infratrochlear nerve
    • Cheek, nose block: Infraorbital nerve (V2)
    • Zygomaticotemporal nerve block
    • Maxillary nerve block: greater palatine foreman
    • Mental nerve block
    • Auricular block
    • Cervical plexus block

References: 

  1. Niamtu III J. Local anesthetic blocks of the head and neck. In: Shiffman M, Mirrafati S, Lam S, Cueteaux C (eds.) Simplified Facial Rejuvenation. Springer-Verlag Berlin Heidelberg; 2008:29-43. 
  2. Giordano CN, Nelson J, Kohen LL, Nijhawan R, Srivastava D. Local Anesthesia: Evidence, Strategies, and Safety.  Current Dermatology Reports. 2015 Sept;4(3):97-104.
Procedural Sedation

Learning Objectives:

  1. Describe the Joint Commission on Accreditation of Healthcare Organization levels of sedation and associated risks
    • Analgesia
    • Minimal sedation
    • Moderate sedation with analgesia
    • Deep sedation with analgesia
    • General anesthesia
    • Dissociative sedation
  2. Understand common intravenous medications utilized for procedural sedation to include pharmacokinetics, patient selection, dosage, rate of onset, side effects and contraindications
    • Propofol
    • Etomidate
    • Benzodiazepines
      • Midazolam
    • Opioids
      • Fentanyl
      • Remifentanil
      • Alfentanil
    • Ketamine
    • Barbiturates
      • Methohexital
    • Nitrous oxide (N2O)
  3. Outline commonly co-administered medications to include rationale
  4. Describe common otolaryngology indications for total intravenous anesthesia (TIVA) and the associated risks

References:

  1. Frank RL. Procedural sedation in adults outside the operating room. In Grayzel J (Ed.) 
The Difficult Airway and Associate Emergencies

Learning Objectives

  1. Describe the application, risks and benefits of various resuscitation equipment to include:
    • Bag-mask device
    • Nasal airway
    • Oral airway
    • Laryngeal mask airway (LMA)
    • Video assisted laryngoscope
    • Rigid laryngoscope
    • Rigid bronchoscope
  2. List alternative options for airway establishment went traditional oral intubation is not achievable
    • Awake fiberoptic intubation
    • Awake tracheostomy
    • Transtracheal jet ventilation
  3. Describe the indications, pertinent anatomic landmarks, equipment, surgical steps and potential complications of emergency surgical airway management to include:
    • Open tracheostomy
    • Percutaneous tracheostomy
    • Cricothyrotomy
  4. Pediatric foreign body
    • Outline most common anatomic location for tracheobronchial foreign body aspiration
    • Recognize clinical symptoms and radiographic findings consistent with foreign body aspiration
    • List the advantages and disadvantages of flexible versus rigid bronchoscopic removal of pediatric foreign bodies.  

References

  1. Ruiz FE. Airway foreign bodies in children. In: Hoppin AG eds. 
  2. Ghatti NI.  Surgical management of the difficult airway.  In Flint PW, Haughey BH, Lund VJ, Niparko JK, et al. eds. Cummings Otolaryngology Head and Neck Surgery, 6th Ed.  Philadelphia, PA: Elsevier Saunders; 2011:86-94. 
  3. Kraft SM, Schindler JS. Tracheotomy.  In Flint PW, Haughey BH, Lund VJ, Niparko JK, et al. eds. Cummings Otolaryngology Head and Neck Surgery, 6th Ed.  Philadelphia, PA: Elsevier Saunders;  2011:95-103. 
Anesthesia and Airway Complications

Learning Objectives

  1. Understand the pathophysiology, presenting symptoms, and management of anesthesia and airway complications to include:
    • Airway fire
    • Post-obstructive pulmonary edema
    • Tension pneumothorax
    • Malignant hyperthermia
    • Laryngospasm
    • Post-tonsillectomy bleed

Reference

  1.  Mark LJ, Hillel AT, Herzer KR, Akst SA, Michelson JD.  General considerations of anesthesia and management of the difficult airway. In Flint PW, Haughey BH, Lund VJ, Niparko JK, et al. eds. Cummings Otolaryngology Head and Neck Surgery, 6th Ed. Philadelphia, PA: Elsevier Saunders;  2011:64-85.
Review Questions
  1. What is the most common anatomic location for a pediatric tracheobronchial foreign body aspiration?
  2. What common medication is used to provide dissociative sedation during which patients experience profound analgesia and amnesia while maintaining spontaneous respiration and cardiopulmonary stability?
  3. Which short acting agent is best used for conscious sedation in the elderly population?
  4. What are the most common late complications of a tracheotomy?
  5. What is the most appropriate treatment for an otherwise healthy 23 year old who develops fever, tachycardia, cyanosis and hypercarbia two hours into surgery under general anesthesia?
Resources 

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  1. Annual Meeting Webcast (AMW):