Anesthesia for Otolaryngologic Surgery

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Many nonprescription cold medications and antihistamines contain aspirin, which may affect platelet function, and this potential anticoagulation should be taken into consideration. Chest radiographs and electrocardiograms ECGs are not required unless specific abnormalities are elicited during the history, such as recent pneumonia, bronchitis, upper respiratory infection URI , or history consistent with cor pulmonale, which is seen in children with obstructive sleep apnea syndrome. In those children with a history of cardiac abnormalities, an echocardiogram may be indicated.

Classification of tonsil size, including percentage of oropharyngeal area occupied by hypertrophied tonsils. OSAS is characterized by periodic, partial, or complete obstruction of the upper airway during sleep. The STOP questionnaire has been developed as a tool to screen adult patients for obstructive sleep apnea and includes information on Snoring, daytime somnolence and Tiredness, Observation of apnea during sleep and elevations in blood Pressure.

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Predicting risk in children, however, is far more complicated. Individuals who experience obstruction during sleep may have snoring loud enough to be heard through closed doors or observed pauses in breathing during sleep. They may awaken from sleep with a choking sensation. Parents report restless sleep in affected children and frequent somnolence or fatigue while awake despite adequate sleep hours. These children fall asleep easily in nonstimulating environments and are difficult to arouse at usual awakening time.

Obesity changes craniofacial anthropometric characteristics. Many of these children have syndromes which are associated with additional comorbidities. Anatomic nasal obstruction and Class 4 touching tonsils reduce oropharyngeal cross-sectional area which constitutes an additional risk. Pharyngeal size is determined by the soft-tissue volume inside the bony enclosure of the mandible; an anatomic imbalance between the upper airway soft-tissue volume and craniofacial size will result in obstruction.

The magnitude of pharyngeal muscle contraction is controlled by neural mechanisms and the interaction between the anatomical balance and neural mechanisms determines pharyngeal airway size. Increased neural mechanisms can compensate the anatomical imbalance in obstructive sleep apnea patients during wakefulness.

When these neural mechanisms are suppressed during sleep or anesthesia, pharyngeal dilator muscles do not contract maximally and therefore the pharyngeal airway severely narrows because of the anatomical imbalance. Increasing bony enclosure size will provide relief of airway obstruction.

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This is only accomplished surgically by mandibular advancement. Increasing the distance between the mentum and the cervical column by positioning will transiently relieve the obstruction as long as the sniffing position is maintained. Similarly, the sitting position displaces excessive soft tissue outside the bony enclosure through the submandibular space.

The long-term effects of OSAS are not limited to the airway. These children have other systemic comorbidities. Increased body mass index and obesity may lead to increased cognitive vulnerability as illustrated by the increased frequency of hyperactivity and increased levels of C-reactive protein. The duration of OSA has no relation to reversibility of neurobehavioral impairment since many believe that episodic hypoxia alters the neurochemical substrate of the prefrontal cortex causing neuronal cell loss.

Metabolic syndrome consists of insulin resistance, dyslipidemia, and hypertension. It is felt that OSAS is a risk factor for metabolic syndrome in obese children but not in nonobese patients. Cardiovascular and hemodynamic comorbidities are more common in OSAS patients. These consist of altered regulation of blood pressure as well as alterations in sympathetic activity and reactivity.

Also present are endothelial dysfunction and initiation and propagation of inflammatory response facilitated by increases in levels of C-reactive protein. Systemic inflammation using interleukins as a marker is a component of OSAS in both obese and nonobese children and is reversed after tonsillectomy. Systemic hypertension, changes in left ventricular geometry, and intermittent hypoxia leading to pulmonary artery hypertension are well-described comorbidities present in patients with OSAS. Recurrence may occur in children with craniofacial abnormalities and in others.

Vladimir Nekhendzy

If surgical intervention does not resolve the problem, nocturnal CPAP is the next treatment modality. However, many of these children may present for imaging studies or require sedation prior to removal of the tonsils or adenoids. Anesthetic Management The goals of the anesthetic management for tonsillectomy and adenoidectomy are to render the child unconscious in the most atraumatic manner possible, to provide the surgeon with optimal operating conditions, to establish intravenous access to provide a route for volume expansion and medications when necessary, and to provide rapid emergence so that the patient is awake and able to protect the recently instrumented airway.

Premedication may be used as determined by the anesthesiologist during the preanesthetic visit. Sedative premedication should be avoided in children with obstructive sleep apnea, intermittent obstruction, or very large tonsils. Administration of opiates to patients with obstructive sleep apnea is associated with an increased risk of oxygen desaturation secondary to chronic hypoxemia and alterations in respiratory control.

Anesthesia is commonly induced with a volatile anesthetic agent, oxygen, and nitrous oxide N 2 O by mask. Parental presence in the operating room OR during mask induction may be helpful in the anxious unpremedicated child. Tracheal intubation is best accomplished under deep inhalation anesthesia or aided by a short-acting nondepolarizing muscle relaxant. Many clinicians may choose to eliminate the neuromuscular blocking agent in favor of enhancing the depth of anesthesia with the use of propofol.

The addition of 0. For this reason, the supraglottic area may be packed with petroleum gauze, or a cuffed endotracheal tube may be used. If a cuffed endotracheal tube is selected, careful attention to the inflation pressure of the cuff is essential if postextubation croup is to be avoided. Monitoring consists of precordial stethoscope, ECG, automated blood pressure, pulse oximetry, and end-tidal capnography.

Anesthesia in otolaryngologic surgery; the preparation of the patient. - Abstract - Europe PMC

Emergence from anesthesia should be rapid, and the child should be alert before transfer to the recovery area. The child should be awake and able to clear blood or secretions from the oropharynx as efficiently as possible before removal of the endotracheal tube. Maintenance of airway and pharyngeal reflexes is essential in the prevention of aspiration, laryngospasm, and airway obstruction. There is no difference in the incidence of airway complications on emergence between patients who are extubated awake or deeply anesthetized.

The flexible model has a soft, reinforced shaft that easily fits under the mouth gag without becoming dislodged or compressed. Adequate surgical access can be achieved, and the lower airway is protected from exposure to blood during the procedure. The same depth of anesthesia should be obtained during insertion of the LMA as would be required for performing laryngoscopy and endotracheal intubation.

Positive-pressure ventilation should be avoided when the LMA is used during tonsillectomy, although gentle assisted ventilation is both safe and effective if peak inspiratory pressure is kept below 20 cm H 2 O.


Tonsillar enlargement can make LMA insertion difficult; care in placement is essential. Dislodgment of the device does not occur during extreme head extension, assuming good position and ventilation were obtained before changes in head position. If the child is breathing spontaneously at a regular rate and depth, the LMA may be removed before emergence from anesthesia.

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It is often distressing for young children to awaken with the LMA still in place. Although the device is an appropriate substitute for an oral airway in the adult population, this is not so in children. If the practitioner wants to remove the LMA when the child has emerged from anesthesia, it should be deflated and removed as soon as possible after the return to consciousness. Create File.

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Contemp Anesth Pract. Cork RC. Abstract Many additional considerations go into the anesthetic management of an otolaryngologic case involving laser surgery. Supplemental Content. External link. Find out about Lean Library here. Skip to main content. Article Menu. Download PDF. Cite Citation Tools. How to cite this article If you have the appropriate software installed, you can download article citation data to the citation manager of your choice. Download Citation If you have the appropriate software installed, you can download article citation data to the citation manager of your choice.

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