Chapter 71. ENT Procedures

Preoperative Considerations

• Seek history of obstructive sleep apnea (OSA), bleeding disorders, loose teeth, sickle cell
• OSA and tonsillar hypertrophy = airway obstruction
• Inspect oropharynx: percentage of area occupied by hypertrophied tonsils correlates with ease of mask ventilation
• Check hematocrit, use of ASA or other anticoagulants
• High incidence of PONV
• Consider vigorous IV hydration to counteract dehydration due to poor oral intake

Anesthetic Plan

• Aim: rapid emergence to alertness prior to leaving OR. Ability to clear secretions and protect airway is key
• Avoid sedative premedication in patients with OSA or large tonsils
• IV induction for adults. Mask induction with N2O, O2, and volatile agent for children
• Consider oral RAE
• PONV prophylaxis with ondansetron, dexamethasone
• Decompress stomach with orogastric tube prior to emergence (swallowed blood is a potent emetic)

Perioperative Pearls

• Up to 8% experience postoperative hemorrhage. Usually occurs within 24 hours of surgery, may occur 5–10 days postoperatively
• Chronic hypoxemia, hypercarbia = increased airway resistance leads to cor pulmonale
• Note EKG for findings of RVH, dysrhythmias; CXR with cardiomegaly
• CXR or TTE may be indicated in patients with suspicion of cor pulmonale

Preoperative Considerations

• Hemorrhage rate higher in adults, male gender, and presence of peritonsillar abscess
• Check Hgb, Hct (might not drop if acute bleeding; estimate bleeding clinically based on hemodynamic response), and coagulation
• Type and cross-match ready
• Hypotension a late symptom

Anesthetic Plan

• Oxygenate and resuscitate first
• Dependable large-bore IV access
• Anticipate difficult laryngoscopy: clots, bleeding, swelling, and edema
• Use smaller ETT
• Rapid sequence induction (RSI): preferred but patient may inhale blood, CV depression on top of hypovolemia
• 2 wall suctions available
• Head-down position for intubation
• Decompress stomach with orogastric tube to clear blood after securing airway
• Extubate when fully conscious and able to protect airway

Perioperative Pearls

• Rebleeds usually occur within 6 hours of surgery
• Bleeding may be occult
• Problems usually due to aspiration, hypovolemia, difficult laryngoscopy

• Pediatric patients with recurrent otitis media frequently have URIs as well
• Okay to do surgery on most patients with URI; just give postoperative O2
• Short, same-day surgeries
• Avoid premedication due to short duration of surgery
• Consider mask ventilation with volatile anesthetic, N2O, and oxygen for surgery
• The only case that can be performed without inserting an IV

Preoperative Considerations

• High incidence of PONV
• Mastoid surgery: facial nerve usually monitored

Anesthetic Plan

• Mask for IV induction for children; IV induction for adults
• Neck turned laterally. Be careful of positioning
• Facial nerve monitoring = no NMB during case
• Avoid N2O: middle ear is air-filled, nondistensible spaces
• No NMB and no N2O means high-dose volatile agent or propofol infusion
• Consider relative hypotension MAP 20% below ...