:

Preface

Clinical approach to ENT anesthesia involving the Nose Part 2 Ent colloquia

General principles Surgical and Anesthetic Goals and Results are directly linked through basic knowledge of Anatomy and the Procedure Carefully detailed Plan for a “fluid” perioperative experience Atraumatic intubation Sharing of the airway while allowing optimal surgical exposure Helping to control blood loss and secretions SMOOTH EMERGENCE

Anesthetic Plan Intelligent Anticipation and Vigilance Patient information Knowledge and expectations of the procedure Spatial arrangement in O.R.

Atraumatic Intubation

Traumatic Intubation

Sharing the Airway while maintaining optimal surgical exposure

Control of blood loss and secretions Surgeon Anesthesiologist Complexity of the case Well functioning equipment Head positioning

SMOOTH EMERGENCE Valsalva effect Airway “bucking on the tube” Intolerance to ETT (if used) Blood and/or secretions Nausea Pain

ANATOMY of the NOSE External Nose- nares and Ala Nasal Cavity (nasal fossae) Nasal Septum Lateral Nasal Wall Nerves Vessels

Anatomy External nose nasal skeleton nasal bones nasal cartilages blood supply Innervation

Skeleton of the Nose

Blood supply of the external Nose

Innervation of the skin

NASAL CAVITY

Nasal Septum

Lateral Nasal Wall

General distribution of Nerves to the Lateral Nasal Wall

The Anterior Ethmoidal and the Sphenopalatine nerves

Arteries of the Lateral Nasal Wall

The Septorhinoplasty

Application of the principles Linking techniques with the surgeons needs Critical points of the surgery Postoperative requirements

Anesthetic plan 3 variables Patient Case general concerns surgeons skills anesthesiologist skills location of procedure

Patient Expectations What do I tell them before the surgery?

Room Preparation

Workstation

Specific equipment Oral packing sponges Airway Devices Infusion pump with extension Clear eye tape

Patient positioning Arms generally tucked Head secured and slightly elevated

Positioning the Monitors on the Patient Based on Patient positioning Leg to Head? Or Head to Leg? BP Cuff Twitch Monitor?

Induction: Endotracheal intubation Premedication Patient Positioning Anxiolytics Induction

Intubation Protect the eyes during Bag-Mask Ventilation with Clear Tape Muscle relaxant The ETT

Maintenance Securing the ETT and the circuit Preparing for the Epi/Local injection Preparing for the other Critical portions Preparing for a smooth extubation

Emergence Optimize patient blood pressure Put pt in beach chair/sitting position IV Tylenol infusion Remove Packing Lower cuff pressure Watch patient very carefully for emergence…it happens quickly!

Exceptions to the Rule Android Morbid Obesity Smokers Teenagers OSA and pulmonary Disorders

Android Morbid Obesity

Smokers

Teenagers

OSA

Pulmonary Pathology

Postoperative concerns

Conclusion: General principles Surgical and Anesthetic Goals and Results are directly linked through basic knowledge of Anatomy and the Procedure Carefully detailed Plan for a “fluid” perioperative experience Atraumatic intubation Sharing of the airway while allowing optimal surgical exposure Helping to control blood loss and secretions SMOOTH EMERGENCE

References Hollingshead. Anatomy for surgeons, Vol 1, third edition Nunn,J. Drury, Anesthesia for ENT surgery, 4th edition, Vol 2 Anesthesia in endoscopic sinus surgery, European Archives of Oto-Rhino Laryngology , Vol 260, num.9,481-486,2003