EYE, E.N.T.

& DENTAL ANAESTHESIA

by Dr. J.K.H. De Silva Consultant Anaesthetist T.H.K.

Anaesthesia for ENT Surgery

Anaesthesia for ENT Surgery

Bleeding tonsil FB removal

Epiglottitis
Peritonsillar abscess ML, DL , oesophagoscopy

General Considerations

- most are young / children - old pts ( tumours ) smokers / alcoholics Airway obstruction if present- consider difficult intubation & Tracheostomy under LA Shared airway - intubation (mostly with RAE tubes) and a throat pack is often required Cocaine spray / Moffetts solution to reduce bleeding Limited access to airway - monitoring with Et CO2 essential Place for hypotensive anaesthesia N.M. blockade is often avoided in parotid sx. N2O may be avoided in middle ear sx. Laser may be used.

Patients

Tonsilectomy / Adenoidectomy
Usually children Premedicate with atropine / glycopyrolate IV / Gas induction Intubation may be difficult ( large tonsil ) RAE tubes preferred ( reinforced oral ETT )

Throat pack +/- ( surgical access )

Antiemetics IV fluids to replace blood loss & fasting

Blood transfusion if loss > 10%

Awake extubation, lateral position KUO for bleeding

Bleeding Tonsil
Problems
Hidden blood loss (most swallowed).
Hypovolaemia may be severe. Risk of aspiration (swallowed blood). Airway management & intubation may be

difficult if bleeding is torrential.

Residual effects of previous anaesthetic

agents.
? un diagnosed coagulation ds. Anxious parents

Bleeding Tonsil cont.

Management

Quick assessment + resuscitation is mandatory IV fluids 20 ml/kg bolus + blood. NG aspirations - controversial. Induction - Gas / RSI Gas in left lat. position with O2 & Halothane. Adv: spont: respiration preserved Disadv: prolong induction Hal:% - BP RSI - TPS (smaller dose) & Sux Adv - rapidity of intubation (smaller size ) NG /OG aspiration before extubation Anti emetics

Nasal Surgeries
*Preparation - prior to induction with moffatts solution ( cocaine, Na Hco3, adrenaline ) *Oral reinforced ETT / RAE tube & throat pack *Avoid hypercarbia and halothane as dysrhythmias are common *Awake lateral extubation *Oro- pharyggeal air way if both nostrils are packed

Inhaled FB removal

Common in children. Stridor / Bronchospasm + oedema. Distal atelectasis / over inflation due to ball-valve effects. Rigid bronchoscopy requiring relaxation ( deep an: / sux ) Airway shaired by aneasthetist and the surgeon Pre-medication with atropine / glycopyrolate Inhalational induction with O2, Halothane /sevoflorane (N2O avoided - ? air trapping) IPPV - may blow the FB further down. - very gentle ( if needed ) Anaesthesia maintained with gases ( 100% O2 & Halothane ) via ventilating bronchoscope May intubate for recovery and extubate awake Post-op laryngo/broncho spasm common (Dexa: 0.1mg/kg) Humidified O2 via mask.

Epiglottises

Haemophilus influenza type B. Children 2 3 years, adults. Present with - (i) fever (ii) upper airway obstruction (stridor) (iii) sitting position, open drooling mouth. Complete airway obstruction ( if pharyngeal examination, iv cannulation, ect) Clinical diagnosis no need of X-rays. Tracheal intubations is usually required. Experienced Anaesthetist and ENT Surgeon.

Epiglottitis cont..

Gas induction with O2 + Halothane.

Child in sitting position,on mothers lap Monitoring & iv cannulation only after deepening. Intubation - difficult, smaller tube. Urgent tracheostomy may be needed. ITU / HDU care. IV antibiotics, IV fluids Keep the tube for 24 48 hrs. Humidified O2, sedation. Extubation when clinically better, fever, leak around the tube.

Peri tonsillor / Retropharyngeal Abscess

Gas Induction Smaller tube Careful laryngoscopy (can rupture)

Throat pack

DL / ML / Bronchoscopy
Common considerations

Sharing of airway.(mostly compromised ) Hypertensive response to laryngoscopy & dysrrhythmias Need muscle relaxation ( rigid scopes ) Maintanance of aneasthesia difficult Glycopyrrolate to minimize secretions Good preoxygenation Post op: laryngeal spasm

DL
If no airway obstruction, induce with tps & sux Ventilate with 100% O2

hand over the airway to the surgeon

ML -Pass a smaller Ett ( 5 6 min ) if takes >15min nasally (ant: lessions), orally (post: lessions) - (Sanders) Injector technique Bronchoscopy - ventilating bronchoscopy.

Laryngectomy
Patients - smokers +/- RS and CVS problems Lung function test & chest physiotherapy Presence of stridor Gas induction Prolong surgery with considerable blood loss ETT is withdrown and a laryngectomy tube or

tracheostomy tube is inserted Sterile connectors should be kept ready Post op care ideally in ITU / HDU

Middle Ear Surgery

Hypotensive aneasthesia was the practice to

minimise bleeding ( microscopic veiw ) Good premedication , head up position Normocarbia to avoid vasodilatation Rise in middle ear prs can dislodge the graft Avoid N2O or off 10 min before end Anti emetic therapy

Anaesthesia for Dental Surgery

Anaesthesia for Dental Surgery

Tooth extractions. Cleft lip & cleft palate.

wiring
Faciomaxilalry

cosmetic cancer

Gas Extraction

Principles are as for day case surgery. Anxious, unpremedicated children / mentally handicapped. Pre-op assessment + adequate fasting. Children with Heart disease prior to surgery. Gas induction with O2, N2O halothane. Arrhythmias common Ett.+ a throat pack if - impacted tooth / multiple teeth - bleeding disorders
Place for LMA ? Close co-operation between Anaesthetist & Surgeon.

Analgesics - Diclofenac sodium PR (prior to induction ) IV opioids ? IV antibiotics - Heart disease Recovery in lateral position with slight head down. Post-op laryngeal spasm

Cleft Lip / Cleft Palate

Problems of Paediatric age group. Difficult intubation.

Use of RAE (curved) tubes.

Throat pack. Monitoring with EtCO2 (for obstruction)

Blood loss is usually minimal.

IV fluid - N/2 saline.

Faciomaxillary Surgery

Restricted mouth opening

Gas induction & blind nasal intubation Awake fibreoptic intubation Tracheostomy under LA.

Reinforced nasal tube & throat pack Blood loss Antiemetics