Middle ear disease requiring surgery affects patients of all ages. Common middle ear surgeries in children include myringotomy, tympanoplasty, and mastoidectomy, whereas common middle ear surgeries in adults include tympanoplasty, stapedectomy or ossiculoplasty, mastoidectomy, and removal of cholesteatoma. Some of these procedures can be performed under local anesthesia, although general anesthesia is often required. Primary anesthetic considerations include attention to patient positioning, facial nerve preservation, adequate hemostasis, use of nitrous oxide, smooth emergence, and prevention of PONV.

Common nasal and sinus surgical procedures include rhinoplasty (functional and/or cosmetic), functional endoscopic sinus surgery, and skull base approaches to neurosurgical procedures. Newer developments in endoscopic surgeries include stereotactic guidance systems, which permit real-time guidance of surgical instruments based on imaging. Superficial nasal surgery can be performed in a physician’s office with local anesthesia or sedation while general anesthesia is used for longer and more invasive procedures in order to provide immobility, airway protection, and amnesia. A special consideration in nasal surgery is the use of vasoconstrictors such as cocaine or epinephrine administered by the surgeon to reduce bleeding. These agents may have profound effects on the cardiovascular system including tachycardia, hypertension, and arrhythmias. These effects are particularly significant in the elderly and in patients with preexisting cardiac disease.

Tonsillectomy, one of the most common performed airway procedures in children, is performed for the treatment of chronic or recurrent tonsillitis or obstructive tonsillar hyperplasia. Children with adenotonsillar hypertrophy can present with nasal obstruction, recurrent infections, obstructive sleep apnea, otitis media, and deafness due to Eustachian tube dysfunction. Preoperative assessment should focus on airway considerations including history of recent URI, history of obstructive sleep apnea (OSA), presence of loose teeth, as well as assessment for presence of bleeding disorders. Patients with a recent upper respiratory tract infection are at increased risk for airway reactivity and laryngospasm, while patients with OSA are often obese and may pose difficulties with airway management.

Children often receive an inhalational induction followed by IV placement. Continuous positive end-expiratory pressure during induction may be beneficial in reducing airway obstruction. Placement of a cuffed endotracheal tube (ETT) will reduce the risk of aspiration of blood during the surgical procedure. Oral RAE tubes (Fig. 37.1) may provide better visualization of the surgical field and be less prone to kinking with placement of retractors. Some centers commonly use a flexible LMA for performing this procedure (Fig. 37.2). In addition, supraglottic packing may be inserted to limit drainage of blood during the procedure. At the end of the procedure, the throat pack should be removed, the stomach emptied with an oro- or nasogastric tube, and the oropharynx suctioned. Prophylactic antiemetics should be administered to decrease the high incidence of PONV. Tracheal extubation should be performed when the patient is awake and able to protect his airway.

Hemorrhage from a bleeding tonsil in the postoperative period is a recognized complication of tonsillectomy and is a surgical emergency. Post-tonsillectomy hemorrhage most commonly occurs with 24 h of surgery (primary hemorrhage) but can occur anytime thereafter. The anesthetic risks in a patient with a bleeding tonsil include hypovolemia, risk of pulmonary aspiration of blood, and potential risk of a difficult intubation due to the presence of ongoing bleeding. Appropriate intravenous access and fluid resuscitation are needed before reoperation since induction in a hypovolemic child can precipitate cardiovascular collapse. Hemoglobin, coagulation studies, and the availability of blood products should be ascertained, and transfusion should occur as needed. Preoxygenation and rapid sequence induction should be performed to ensure rapid control of the airway. Slight head-down position during induction may protect against pulmonary aspiration of blood or stomach contents. Prior to extubation a nasogastric tube should be used to empty the stomach. Extubation should be performed with the patient fully awake and able to protect his airway. Postoperatively, the patient should be closely monitored for the occurrence of rebleeding.

Tracheostomy is an operative procedure which creates a surgical airway in the cervical trachea. Tracheostomy is most commonly performed in patients who cannot be liberated from mechanical ventilation and who have suffered severe trauma or neurologic insult and need ongoing pulmonary toilet or in order to bypass the upper airway in cases of head and neck cancers. Advantages of tracheostomy over endotracheal intubation include improved patient comfort, decreased requirements for sedation, more effective pulmonary toilet, and increased airway security. There are two types of tracheostomy placement: surgical and percutaneous dilatational. While surgical tracheostomy is generally performed in the operating room, percutaneous dilatational tracheostomy lends itself to being performed at the bedside in the intensive care unit.

Head and neck surgery for cancer composes a diverse group of procedures that may include laryngectomy, pharyngectomy, hemimandibulectomy, parotidectomy, or radical neck dissection. A variety of macrosurgical and microsurgical techniques involving soft tissue and bone may be used and tissue flap reconstruction may be required. These cases can be complex and lengthy. A thorough preoperative assessment is important since patients scheduled for head and neck surgery are often elderly and have a variety of comorbidities including hypertension, coronary artery disease, and chronic obstructive pulmonary disease from smoking and heavy alcohol use. In addition, they are often debilitated and suffer from malnutrition resulting from the effects of cancer.

Primary anesthetic concerns include establishing and maintaining a secure airway, preparation for bleeding, and nerve monitoring. Distortion of the oropharyngeal and/or laryngeal structures may result from tumor, prior surgery, or radiation treatment. In addition, radiation may lead to complications such as tissue friability and fibrosis or spondylosis of the temporomandibular joint, resulting in limited mouth opening or neck mobility. A well thought-out plan for airway management is essential; this might require an awake fiberoptic intubation or that an elective tracheostomy is performed under local anesthesia. In cases with potential for airway difficulty, the surgeon should be present and be prepared to perform an emergent surgical airway if needed. Given the proximity of the surgery to the airway, a wire reinforced (“armored”) endotracheal tube may be beneficial to prevent kinking during the surgical procedure. The anesthesiologist must be vigilant to detect instances of unintended extubation.

In cases of flap reconstructive surgery, attention must be paid to providing adequate perfusion to the flap both during harvest and after implantation through maintenance of normothermia and ensuring adequate hydration. Minimizing the use of vasoconstrictors may also be desirable, although recent data indicate that vasopressor use during flap creation does not significantly increase the rate of graft failure or complications. Close communication with the surgical team will help to provide appropriate care in each case.

Larger head and neck reconstructive procedures can be notable for their length and potential for blood loss. The anesthesiologist should consider placement of large-bore intravenous access and intra-arterial blood pressure monitoring (especially as dictated by comorbidities) and ensure blood product availability. During surgical dissection, traction or pressure on the carotid sinus or stellate ganglion can cause wide fluctuations in blood pressure and dysrhythmias including bradycardia and asystole. The treatment is immediate cessation of the stimulus. Infiltration of the carotid sheath with local anesthetic may mitigate such effects. Neck dissection entails risk of injury to a number of nerves. Accordingly, peripheral nerve monitoring is frequently employed, posing a contraindication to long-acting neuromuscular blockade.

Postoperatively, the anesthesiologist should be aware of the potential for nerve injury and the presence of laryngeal edema following surgical manipulation. If airway compromise is anticipated postoperatively, then the patient should be left intubated and an elective tracheostomy may need to be performed. Injury to the recurrent laryngeal nerve can cause vocal cord dysfunction, with bilateral injury causing airway obstruction. Phrenic nerve injury can result in hemidiaphragmatic paralysis. Hematoma formation in the neck can rapidly result in airway compromise. Following laryngectomy, all caretakers should be aware that there no longer exists a conduit between the oropharynx and the trachea. Mask ventilation and intubation from above will be impossible; these may only be accomplished via the tracheostomy.

Patients with laryngeal pathology are potentially difficult to ventilate and intubate. Patient symptoms and physical examination findings provide indicators of potential airway difficulty. Symptoms such as hoarseness or stridor may be indicators of vocal cord involvement, while dyspnea and shortness of breath may occur as a result of mass effect or cord fixation. Prior surgery and radiation can cause anatomic distortion and dysfunction and may increase the risk of aspiration and hemorrhage. During the basic physical examination, the neck should be palpated for evidence of masses, tracheal deviation, and tissue plasticity. Recent results of imaging studies can be useful in assessing the extent of airway compromise. If potential problems with a patient’s airway are identified, an approach should be devised for establishing adequate airway control. Both the patient and the surgical team should be informed of the options discussed, including elective tracheostomy. Plans may need to include having a surgeon and instruments on hand for an emergency tracheostomy.

Surgery on the larynx and glottic structures commonly utilizes suspension microlaryngoscopy, a suspension laryngoscope in conjunction with an operating microscope. Using a supportive apparatus, the patient’s head and neck are suspended from the bed, permitting visualization and bimanual access to the surgical field. Microlaryngoscopy is widely used for diagnosis of laryngeal lesions, biopsy, and resection of vocal cord tumors. Anesthetic technique must provide a secure airway, adequate ventilation, immobile vocal cords, and no risk of combustion, without time limitation for operative intervention.

Maxillofacial reconstruction is performed to repair facial trauma or correct facial deformity. Fractures of the midface are described by the plane of injury according to the Le Fort classification (Fig. 37.3). A type 1 Le Fort fracture is a horizontal maxillary fracture, separating the teeth from the upper face. The fracture line passes through the alveolar ridge, lateral nose, and inferior wall of the maxillary sinus. A type 2 Le Fort fracture is a pyramidal fracture, with the teeth at the pyramid base and nasofrontal suture at its apex. The fracture arch passes through the posterior alveolar ridge, lateral walls of the maxillary sinuses, inferior orbital rim, and nasal bones. In a type 3 Le Fort fracture, the fracture line passes through the nasofrontal suture, maxillo-frontal suture, orbital wall, and zygomatic arch resulting in complete craniofacial separation. Le Fort fractures are created for certain types of cosmetic surgery. Although nasotracheal intubation facilitates better access for repair of facial fractures, orotracheal intubation is necessary when intranasal damage is present. Nasal intubations are contraindicated in Le Fort type 2 and type 3 fractures.