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

Patients

- 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.

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 )
Anaesthetic maintained with gases ( 100% O2 & Halothane ) via
ventilating bronchoscope
May intubate for recovery and extubate awake
Post-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 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,

the tube.

fever, leak around

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 &

dysrhythmias
Need

muscle relaxation ( rigid scopes )

Maintanance

of aneasthesia difficult

Glycopyrrolate
Good
Post

to minimize secretions

preoxygenation

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 - nu of 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
Difficult
Use

of Paediatric age group.

intubation.

of RAE (curved) tubes.

Throat

pack.

Monitoring
Blood
IV

with EtCO2 (for obstruction)

loss is usually minimal.

fluid - N/2 saline.

Faciomaxillary Surgery
Restricted

mouth opening

Gas induction & blind nasal intubation

Awake fibreoptic intubation
Tracheostomy under LA.

Reinforced
Blood

nasal tube & throat pack

loss
Antiemetics