EYE, E.N.T. & DENTAL ANAESTHESIAby

Dr. J.K.H. De SilvaConsultant Anaesthetist T.H.K.

Anaesthesia for ENT Surgery

Anaesthesia for ENT Surgery Bleeding tonsil FB removal EpiglottitisPeritonsillar abscess ML, DL , oesophagoscopy

General ConsiderationsPatients- most are young / children - old pts ( tumours ) smokers / alcoholicsAirway 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.

Tonsilectomy / Adenoidectomy Usually childrenPremedicate with atropine / glycopyrolateIV / Gas inductionIntubation may be difficult ( large tonsil )RAE tubes preferred ( reinforced oral ETT )Throat pack +/- ( surgical access )AntiemeticsIV fluids to replace blood loss & fastingBlood transfusion if loss > 10%Awake extubation, lateral positionKUO 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:% - BPRSI - 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 / glycopyrolateInhalational induction with O2, Halothane /sevoflorane (N2O avoided - ? air trapping)IPPV - may blow the FB further down. - very gentle ( if needed ) Anaesthetic maintained with gases ( 100% O2 & Halothane ) via ventilating bronchoscope May intubate for recovery and extubate awakePost-op laryngo/broncho spasm (dexamethaxone 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 lapMonitoring & 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 considerationsSharing of airway.(mostly compromised )Hypertensive response to laryngoscopy & dysrhythmias Need muscle relaxation ( rigid scopes )Maintanance of aneasthesia difficultGlycopyrrolate to minimize secretionsGood preoxygenationPost 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 techniqueBronchoscopy - ventilating bronchoscopy.

LaryngectomyPatients - smokers +/- RS and CVS problemsLung function test & chest physiotherapyPresence of stridor Gas inductionProlong surgery with considerable blood lossETT is withdrown and a laryngectomy tube or tracheostomy tube is insertedSterile connectors should be kept readyPost op care ideally in ITU / HDU

Middle Ear SurgeryHypotensive aneasthesia was the practice to minimise bleeding ( microscopic veiw )Good premedication , head up positionNormocarbia to avoid vasodilatationRise in middle ear prs can dislodge the graftAvoid N2O or off 10 min before endAnti emetic therapy

Anaesthesia for Dental Surgery

Anaesthesia for Dental Surgery Tooth extractions. Cleft lip & cleft palate.wiring Faciomaxilalry cosmeticcancer

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 - nu of teeth - bleeding disordersPlace 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 intubationTracheostomy under LA.Reinforced nasal tube & throat pack Blood loss Antiemetics