1. Common ENT Procedures and Anesthesia Choice Franklin L. Scamman, MD September 30, 2002

2. Most Common ENT Procedures at UIHC for 2000-2001 Panendoscopy 1109 Mx and Tubes420 T and/or T and A203 Tracheostomy132 STSG103 Assorted flaps97 Mastoidectomy94 Radical Neck 84 Nasal sinus surgery75 Tympanoplasty54 UP351 Nose fracture40 Cochlear implant37 Nasal septoplasty36

3. References Miller Edition 5. See the scanned document server under faculty lectures Boezaart AP, van der Merwe J, Coetzee AR. Moderate controlled hypotension with sodium nitroprusside does not improve surgical conditions or decrease blood loss in endoscopic sinus surgery. J Clin Anesth. 2001 Jun;13(4):319-20.

4. References Degoute CS, Ray MJ, Manchon M, Dubreuil C, BanssillonV. Remifentanil and controlled hypotension; comparison with nitroprusside or esmolol during tympanoplasty. Can J Anaesth. 2001 Jan;48(1):20-7.Degoute CS, Ray MJ, Manchon M, Dubreuil C, BanssillonV.

5. Panendoscopy (1) Amnesia –Potent agent or propofol Analgesia –Narcotic Meet Surgeon Requirements –Often intense relaxation, sometimes not –Quick emergence

6. Panendoscopy (2) Meet patient requirements –BP control during “light” anesthesia –Heart rate control –Quick resumption of airway protection –No laryngospasm on extubation

7. Mx and Tubes If you can’t make it quiet, make it quick IV? Quiet field for surgeon N 2 O? Quick emergence N and V? Pain Control?

8. T and A Mask induction and IV Straight vs. RAE OET Fluid replacement Postop pain control N and V control Bring-back bleeder

9. Tracheostomy Currently intubated Impending airway obstruction Heliox? Impossible intubation because of tumor Trach with mask anesthesia?

10. Mastoidectomy and other Base of Skull Surgery Turn table 180 degrees OET out opposite operative side Pressure points Control BP on the low side No paralysis for facial nerve preservation Smooth emergence Postop N and V control

11. Radical Cancer Surgery Probably turn 180 Long case For free flaps, keep patient warm Art line Consider 2nd IV Rarely transfuse

12. Tympanoplasty Turn 180 N 2 O off as tympanic graft is placed Non-cough emergence

13. Uvulo Palato Pharyngo Plasty UP3 Most present with obstructive sleep apnea May be difficult mask airway Consider alternative airway such as fiberoptic intubation All sleep apnea has central component leading to apnea evening of POD 0

14. Nose Fracture and Nasal Septoplasty Use oral RAE (in midline if surgeon requests) Bleeding into pharynx--use throat pack to prevent blood in stomach

15. Controlled Hypotension There is only faint evidence that controlled hypotension for ENT surgery reliably decreases blood loss or improves the surgical field.