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2. Characteristic signs and symptoms of acute epiglottitis include
a sudden onset of fever, dysphagia, drooling, thick muffled voice, and preference for the sitting position with the head extended and leaning forward
retractions, labored breathing, and cyanosis when respiratory obstruction is present.
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3. TREATMENT
Direct visualization of the epiglottis should not be attempted in an awake patient because it could lead to airway compromise and death. Interactions with the patient should be kept to a minimum. Stimulation of the patient or the onset of struggling during attempted treatment procedures may result in exacerbation of the airway obstruction.
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4. Induction of anesthesia is often accomplished with the inhalation of sevoflurane (alternatively, halothane) while maintaining spontaneous ventilation. It is important to secure the airway without stimulating the reactive airway. An emergency airway cart and tracheostomy tray should be available and open, with appropriate personnel present should an emergency surgical airway be needed.
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5. Postoperative management takes place in the intensive care unit and consists of continued observation and radiographic confirmation of tracheal tube placement. Tracheal extubation is usually attempted 48 to 72 hours later when a significant leak around the endotracheal tube is present and visual inspection of the larynx by flexible fiberoptic bronchoscopy confirms a reduction in swelling of the epiglottis and surrounding tissue.
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6. Foreign Body in the Airway
Aspiration of a foreign body into the trachea is emergency, especially in the pediatric population. Clinical manifestations of this phenomenon include a sudden onset of difficulty breathing, dry cough, hoarseness, or even wheezing in young children.
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7. This diagnosis should be suspected in any patient who presents with wheezing and a history of coughing or choking while eating.
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8. Most foreign bodies are radiolucent, and the only findings on radiography are air trapping, infiltrate, and atelectasis. Aspirated foreign bodies are considered an emergency requiring removal in the operating room. Inhalation induction of anesthesia with halothane (sevoflurane is an alternative) in oxygen may be prolonged secondary to obstruction of the airway.
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9. Nitrous oxide may be avoided to decrease the likelihood of air trapping distal to the obstruction.
Spontaneous ventilation may be preserved until the location and nature of the foreign body have been determined.
Respiratory compromise secondary to airway edema or infection is a possible complication in the postoperative period
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10. Treatment of foreign body aspiration into the trachea involves special cooperation between the anesthesiologist and the surgeon because care must be taken to avoid converting partial airway obstruction into total obstruction by distal displacement of the foreign body.
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11. TREATMENT
Removal of a foreign body may include awake direct laryngoscopy or performance of a rigid bronchoscopic examination without the application of positive airway pressure.During this period a surgeon should be present and prepared to perform an emergency tracheostomy or cricothyrotomy should total airway obstruction occur.
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12. When a rigid bronchoscope is used, an intravenous anesthetic may be necessary to avoid exposing the surgeon to inhaled anesthetics. All patients should be observed closely during the recovery period for airway edema and respiratory compromise. The use of humidified oxygen is suggested.
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13. Parotid Gland Surgery
Parotid gland surgery is usually performed for tumors and occasionally for treatment of infectious disorders. Some diseases of the parotid gland may be associated with alcohol abuse, and these patients may exhibit signs and symptoms of alcohol-related diseases.
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14. Parotid gland surgery is performed under general anesthesia and often with monitoring of the facial nerve to avoid surgical damage to this important structure. Neuromuscular blocking drugs may be avoided when nerve monitoring is performed, although preservation of a twitch response with a peripheral nerve stimulator should permit identification of skeletal muscle response to direct electrical stimulation of the facial nerve.
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15. when a radical parotidectomy is performed, the facial nerve may be sacrificed and reconstructed with a graft from the contralateral greater auricular nerve. Nasotracheal intubation may be preferable to orotracheal intubation if the mandible has to be dislocated during surgery.
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16. Facial Trauma
Facial fractures are characterized by the Le Fort classification of maxilla fractures .
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18. A Le Fort II fracture also extends across the maxilla, but
A Le Fort I fracture extends across the lower portion of the maxilla but does not continue up into the medial canthal region.
A Le Fort II fracture also extends across the maxilla, but
at a more cephalad level, and it also continues upward to the medial canthal region.
A Le Fort III fracture is a high-level transverse fracture above the malar bone and through the orbits.
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19. It is characterized by complete separation of the maxilla from the craniofacial skeleton. Orotracheal intubation is necessary when intranasal damage is a possibility. In cosmetic surgery, Le Fort fractures are created for cosmetic repair.
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20. Nasal Surgery
Nasal surgery is most often performed for cosmetic purposes or for functional restoration of the upper airway. Functional restoration is usually performed for either congenital or post-traumatic deviations of the septum. Nasal surgery is typically performed in the physician's office with local anesthesia and intravenous sedation.
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21. A special consideration in nasal surgery is drug-induced (cocaine, epinephrine) vasoconstriction of the nasal mucosa to reduce bleeding. These drugs may have a profound effect on the cardiovascular system, especially in elderly patients or those with known cardiac disease. Cardiac dysrhythmias may accompany drug-induced nasal vasoconstriction.
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22. A moderate degree of controlled hypotension combined with head elevation decreases bleeding in the surgical site. Blood may passively enter the stomach during surgery, and placement of an oropharyngeal pack or suctioning of the stomach at the conclusion of surgery may attenuate postoperative retching and vomiting.
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23. Ear Surgery
Placement of myringotomy tubes, tympanoplasty, and placement of cochlear implants are examples of operations that may be characterized as ear surgery. These surgeries usually require general anesthesia and in some cases rely on neuromonitoring.
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24. When nerve monitoring is used, neuromuscular blocking drugs are avoided or the dose is greatly decreased to preserve a skeletal muscle response with peripheral nerve stimulation. Nausea and vomiting are common after ear surgery. Pretreatment with antiemetics and inclusion of propofol and sevoflurane in the management of anesthesia reduces the incidence of postoperative nausea and vomiting after ear surgery.
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25. MYRINGOTOMY AND TUBE INSERTION
Myringotomy with tube insertion is often performed in children with disorders of the middle ear. Premedication is not recommended in these patients because most sedative drugs will outlast the duration of the surgical procedure. Anesthesia may be accomplished with a volatile drug, oxygen, and nitrous oxide administered by facemask.
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26. MIDDLE EAR AND MASTOID
Tympanoplasty and mastoidectomy are common procedures performed on the middle ear and accessory structures. Tracheal intubation should be accomplished with an oral or nasal RAE tube to minimize intrusion into the surgical field. If nitrous oxide is included in the management of anesthesia, it is recommended that this gas be discontinued at least 30 minutes before placement of the tympanic membrane graft to avoid displacement of the graft by outward diffusion of nitrous oxide into the airfilled middle ear.
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27. decompressing the stomach after induction of anesthesia
Tracheal extubation is often accomplished while the patient is still anesthetized to avoid any straining that may displace the tympanic membrane graft or disrupt other repairs. Postoperative nausea and vomiting are a common problem that may be reduced by
decompressing the stomach after induction of anesthesia
limiting the use of opioids,
administering prophylactic antiemetics.
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28. Neck Surgery
Neck dissection may be complete, modified, or functional. Anatomically, the structures principally involved are (1) the sternocleidomastoid muscle, (2) cranial nerve XI, (3) the internal and external jugular veins and carotid artery.
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29. Frequently, neck dissection is performed for removal of a tumor and may also involve partial or total glossectomy. Patients with such tumors may have a history of tobacco and alcohol abuse. Pulmonary disease is likely and is an indication for a preoperative pulmonary workup.
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30. MANAGEMENTOF ANESTHESIA
In a high percentage of cases the neck dissection may be bilateral and a tracheostomy is performed to maintain a patent airway. Upper airway management may be difficult in these patients, especially if there is a history of radiation treatment of the larynx and pharynx or if a mass is present in the oral cavity.
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31. Neuromuscular blocking drugs are avoided or the dose is greatly decreased if neuromonitoring is used. Dissection around the carotid bulb may precipitate bradycardia, which may be treated by the injection of local anesthetic solution into the bulb or by the intravenous injection of atropine or glycopyrrolate. Postoperative laryngeal edema can be a significant problem if drains are not placed in the operative area.
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32. POSTOPERATIVE COMPLICATIONS
In the postoperative period the anesthesiologist should be aware of potential nerve injuries, including facial palsy as a result of surgical damage to branches of the facial nerve. Injury to the recurrent laryngeal nerve can cause vocal cord dysfunction and, if bilateral, results in airway obstruction.
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33. Because the phrenic nerve also traverses through the operative field, paralysis of the hemidiaphragm can occur. Spontaneous breathing is impaired if the phrenic nerve injury is bilateral. Pneumothorax can also occur in the postoperative period. Excessive coughing or agitation can result in hematoma formation and airway compromise.
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34. Awake Intubation
The airway must be anesthetized using a combination of topical anesthesia and superior laryngeal nerve block.
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35. Superior Laryngeal Nerve Block
The external branch of the superior laryngeal nerve innervates the cricothyroid muscle (tensor of the vocal cords), and the internal branch provides sensory innervation from the base of the tongue to the vocal cords.
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36. With the patient lying supine, a 22-gauge needle attached to a syringe containing 2 mL of 2% lidocaine is introduced until it contacts the hyoid bone. When the needle contacts the hyoid bone, it is redirected caudad until it just steps off the bone penetrating the thyrohyoid membrane. After negative aspiration, the local anesthetic is injected, and the block is repeated on the opposite side.
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37. complication
Complications of superior laryngeal nerve block include intravascular injection of local anesthetic solution. (The carotid artery lies just posterior to the site of needle placement for performance of the block.)
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38. Topical anesthesia includes local anesthetic instilled into the nose (a vasoconstrictor such as 0.5% phenylephrine should be added to shrink the nasal mucosa), mouth (nebulized in a hand-held nebulizer and inhaled by the patient), or both. Topical anesthesia may be applied below the level of the vocal cords by introducing a 22-gauge needle through the cricothyroid membrane and rapidly injecting 4 mL of 2% lidocaine. The resulting cough reflex distributes the local anesthetic along the tracheal mucosa and inferior surface of the vocal cords
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39. An LMA may be useful in temporarily securing a compromised airway, and a tracheal tube (guide over a bronchoscope inserted through an LMA) is necessary to protect the airway from aspiration of blood. The LMA- Fastrach is a modification of the intubating LMA that was designed specifically for anatomically difficult airways.
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40. Thanks for your attention
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