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  • Image not available.The anesthetic goals for endoscopy include profound muscle paralysis to provide masseter muscle relaxation for introduction of the suspension laryngoscope and an immobile surgical field, adequate oxygenation and ventilation during surgical manipulation of the airway, and cardiovascular stability during periods of rapidly varying surgical stimulation.
  • Image not available.It is crucial to monitor chest wall motion constantly and to allow sufficient time for exhalation to avoid air trapping and barotrauma.
  • Image not available.The greatest fear during laser airway surgery is a tracheal tube fire. This can be avoided by using a technique of ventilation that does not involve a flammable tube or catheter (eg, intermittent apnea or jet ventilation through the laryngoscope side port).
  • Image not available.Techniques to minimize intraoperative blood loss include supplementation with cocaine or an epinephrine-containing local anesthetic, maintaining a slightly head-up position, and providing a mild degree of controlled hypotension.
  • Image not available.As always, if there is serious doubt regarding potential airway problems, an intravenous induction should be avoided in favor of awake direct or fiberoptic laryngoscopy (cooperative patient) or an inhalational induction, maintaining spontaneous ventilation (uncooperative patient). In any case, the equipment and personnel required for an emergency tracheostomy must be immediately available.
  • Image not available.The surgeon may request the omission of neuromuscular blocking agents during neck dissection or parotidectomy to identify nerves (eg, spinal accessory, facial nerves) by direct stimulation and to preserve them.
  • Image not available.Manipulation of the carotid sinus and stellate ganglion during radical neck dissection (right side more than the left) has been associated with wide swings in blood pressure, bradycardia, dysrhythmias, sinus arrest, and prolonged QT intervals. Infiltration of the carotid sheath with local anesthetic will usually ameliorate these problems. Bilateral neck dissection may result in postoperative hypertension and loss of hypoxic drive because of denervation of the carotid sinuses and bodies.
  • Image not available.Patients undergoing maxillofacial reconstruction or orthognathic surgical procedures often pose the greatest airway challenges to the anesthesiologist. If there are any anticipated signs of problems with mask ventilation or tracheal intubation, the airway should be secured prior to induction.
  • Image not available.If there is a chance of postoperative edema involving structures that could obstruct the airway (eg, tongue), the patient should be carefully observed and perhaps should be left intubated.
  • Image not available.Nitrous oxide is either entirely avoided during tympanoplasty or discontinued prior to graft placement.

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Never are cooperation and communication between surgeon and anesthesiologist more important than during head and neck surgery. Establishing, maintaining, and protecting an airway in the face of abnormal anatomy and simultaneous surgical intervention can test the skills and patience of any anesthesiologist. Clearly, a thorough understanding of airway anatomy (see Chapter 5) and an appreciation of common otorhinolaryngological and maxillofacial procedures will prove invaluable in handling these demanding anesthetic challenges.

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Endoscopy includes laryngoscopy (diagnostic and operative), microlaryngoscopy (laryngoscopy aided by an operating microscope), esophagoscopy, and bronchoscopy (discussed in Chapter 24). Endoscopic procedures may be accompanied by laser surgery.

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Preoperative Considerations

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Patients presenting for endoscopic surgery are often being evaluated for ...

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