1. Airway anesthesia Dr. S. Parthasarathy MD., DA., DNB, MD (Acu), Dip. Diab. DCA, Dip. Software statistics PhD (physio), FICA

2. Airway access can be extremely challenging in selected cases Facial trauma, TMJ ankylosis, ca cheek, lips etc.. We may need to keep the patient awake but yet intubate These are indications of airway anesthesia

3. Indications Direct laryngoscopy Bronchoscopy Nasal intubation Fiber optic intubation Some procedures on the head and neck

4. When not to proceed A patient on anticoagulation is a relative contraindication Tumors Surgical deformities or reconstruction AV malformations

5. When will the patient accept the tube ? Afferents Airway local Efferents – Muscle relaxants Both – Nerve blocks, deep inhalational anesthesia

6. What all we need to anesthetize ?? Nose Oropharynx Larynx Trachea If we need naso tracheal intubation

7. Direct laryngoscopy awake Salivation, gag Cough Patient will throw us out Sympathetic and parasympathetic

8. Why cant we intubate ?? Gag reflex --- IX vs X Glottic closure reflex --- (SLN Vs SLN + RLN) Cough reflex – X Vs X

9. Anatomy of airway anesthesia The nasal cavity is innervated by the greater and lesser palatine nerves anterior ethmoidal nerve.

10. Anatomy The palatine nerves arise from the trigeminal nerve via the pterygopalatine ganglion and innervate the nasal turbinates and most of the nasal septum. The pterygopalatine ganglion is located posterior to the middle turbinate in the pterygopalatine fossa. The anterior ethmoidal nerve arises from the olfactory nerve (CN I) and innervates the nares and the anterior third of the nasal septum

11. Ant,ethmoidal _ V1 Palatine – V2 Glossopharngeal Lingual – V3 Sup.laryngeal Recurrent lary.

12. The greater and lesser palatine nerves arising from the pterygopalatine ganglion innervate the nasal turbinates and most of the nasal septum.. The anterior ethmoidal nerve arises from the olfactory nerve (CNI) and innervates the nares and the anterior third of the nasal septum.

13. The superior laryngeal nerve provides sensation to the surfaces of the epiglottis and to the airway mucosa to the level of the vocal cords. It provides innervation to the mucosa after entering the thyrohyoid membrane just inferior to the hyoid bone between the greater and the lesser cornua of the hyoid.

14. This mucosal innervation is carried out through the internal laryngeal nerve, a branch of the superior laryngeal nerve. The superior laryngeal nerve also continues as the external laryngeal nerve along the exterior of the larynx; it provides motor innervation to the cricothyroid muscle.

15. The recurrent laryngeal nerve is a branch of the vagus nerve that ascends along the posterolateral margin of the trachea after looping under the right subclavian artery Caudal to vocal cords All intrinsic muscles except cricothyroid

18. Patients should be comfortable like that Before airway blocks Success

19. Premedication drugs

20. Drugs Benzocaine - 20 % spray – 30 seconds – 10 minutes Lignocaine- 1 -2 % infiltration – upto 4 % atomization and spray Adrenaline Bupivacaine - ? Ropivacaine - ?

21. Topical Nerve blocks Or topical + nerve blocks

22. Topical anesthesia Atomizer Nebulizer 4 mL of 4% lidocaine is placed in a standard breathing treatment nebulizer and the patient inhales the vapor 6 ml 10 % ?? Toxic Cotton with local

23. Application of long cotton-tipped applicators soaked in 4% lidocaine with epinephrine or cocaine over the nasal mucosa allows a block of the sphenopalatine ganglion (applicator angled at 45° to the hard palate) and the anterior ethmoid nerve (applicator parallel to the dorsal surface of the nose).

25. Cotton pledgets

27. Cetacaine, is a pressurized solution of benzocaine, tetracaine, and butamben in a small canister, which delivers a spray via a long spray nozzle that is pointed in the desired direction

28. Gargling For oral intubation, gargling of local anesthetic solutions is often used to provide anesthesia to the oral and pharyngeal tissues. 10 ml of a 2% to 4% lidocaine solution are placed in the patient’s mouth, and the patient is instructed to gargle with this solution. The solution is then expectorated to avoid excess local anesthetic absorption. No tracheal or laryngeal action

29. Aspiration 5 ml of 2 –4% lignocaine – dripped in the posterior third of tongue Slowly dripping local Ointment in the end of the tongue depressor Keep it like a lollypop – allow it to melt.

30. IDL Spray the tongue and posterior pharyngeal wall Do an IDL and spray on to the cords

31. Drinking cup – oxygen driven power sprayer

32. Nerve blocks Glossopharyngeal, sup. Laryn.N Rec. laryngeal. N

33. Glossopharyngeal nerve block 9 th cranial nerve – vallecula, epiglottis, tonsil and pharyngeal wall Common – intraoral approach Uncommon – extra oral approach

34. Intraoral With the patient's mouth wide open, a tongue blade held with the nondominant hand is introduced in the mouth to displace the tongue medially, creating a gutter between the tongue and the teeth. The gutter ends posteriorly in a cul-de-sac formed by the base of the palatoglossal arch. A 25-gauge spinal needle is inserted at the base of the cul-de-sac and advanced slightly (0.25 to 0.5 cm). After negative air and blood aspiration tests, 2 mL of 2% lidocaine is injected. The procedure is repeated on the other side

35. Lower part of the posterior pillar of tonsil

36. Extra oral approach Supine Head neutral Midpoint from mastoid process to angle of mandible Perpendicular to skin 1 – 2 cm Hit styloid Walk off posterior Deposit 5 ml

37. Glossopharyngeal nerve

38. Superior laryngeal nerve Hold the hyoid with thumb and index finger Prick medially Just inferior to cornua of hyoid Inject after aspiration Air – larynx – no Blood – no Carotid – pushed 2ml lignocaine Same side push – whole

39. Superior laryngeal nerve - fracture??

40. Recurrent laryngeal nerve Cricothyroid Perpendicular Aspirate and go Air 4 ml of 4 % lignocaine Coughs to spread Topicalization is ideal for RLN

41. RLN ?? Difficult and altered neck anatomy _ ? Can we find Catheter can be left Needle and sheath technique Saline and then local

42. Tips of RLN block The patient needs to be informed that the injection of local anesthetic solution will likely make him cough. Contraindicated -- unstable neck, because it induces coughing. During performance of the block, the patient should not talk, swallow, The catheter should be left in place until the intubation is completed for the purpose of injecting more local anesthetic, if necessary, and to decrease the likelihood of subcutaneous emphysema

43. No blocks – nebulize !! Topical nasal mucosa Atomize nasopharynx and oropharynx FOL - spray 2 ml Epiglottis 2 ml – Glottis 2 ml Trachea 2 ml Spray as you go !! Gel and vasoconstrictors

44. SJA Upper airway blocks provide better quality of anesthesia than lignocaine nebulization as assessed by patient recall of procedure, coughing/gagging episodes, ease of intubation, vocal cord visibility, and time taken to intubate. Invasive blocks – complications – experienced hands

45. Summary Anatomy Nose Blocks Complications Other options