Head and neck surgery uniquely involves a shared surgical field, where even small changes in your anesthetic can affect the operative view. Because of this, the surgeon is heavily reliant on you for safety and optimal conditions.

This is a specialty where preoperative collaboration is critical. Discuss key issues with the surgeon before induction:

• ETT size, material, and route (oral vs. nasal)
  
• Need for reinforced, laser, or neuromonitoring tubes
  
• Neuromuscular blockade goals
  
• Arm positioning and tucking
  
• Blood pressure targets (balance their needs with what is safe for the patient)

Any mass obstructing or extruding into the airway should be considered high risk for postinduction obstruction. The patient may maintain their airway while awake but lose it instantly with sedation.

Review ENT notes and look at flexible laryngoscopy images when available. Have clear contingency plans:

• A, B, and C plans for airway management
  
• Difficult airway cart with videolaryngoscope, fiberoptic scope, oral/nasal airways, LMAs
  
• Meds prepared: paralytic, additional propofol, glycopyrrolate

Once the case starts, you’ll quickly lose access to the head and neck. While you’re securing IVs, hanging antibiotics, and adjusting anesthetics, stay vigilant about:

• the airway and tube position
  
• IV patency
  
• hemodynamic status

If the surgical team is manipulating the airway while you are occupied with another task, don’t hesitate to say, “Please hold for a moment while I stabilize the patient.”

IV access is key: hook up infusions close to the insertion site and ensure easy access to stopcocks. Poor line management can become a big problem during the case.

Avoid unnecessary devices in the mouth or nose (NG tubes, temp probes, oral/nasal airways) unless essential and discussed with the surgical team. They can obviously interfere with the procedure or cause unnecessary trauma.

Cases involving the head and neck vary significantly in their level of stimulation, alternating between highly stimulating phases (laryngoscopy, incisions, cautery) and low-stimulation periods (microvascular dissection).

Patients with head and neck cancers typically have comorbidities like alcohol use, tobacco use, and their sequelae: this usually includes hypertension. Management depends on whether paralysis is desired or contraindicated. Without paralysis, which is often the case, anesthetizing this patient population presents a challenge. You have to keep the patient deep so they don’t move, but also support the hypotension that may result from this deeper plane of anesthesia.

If the case calls for converting from an ETT to a tracheostomy, be prepared for this critical step. At all points in transition, be prepared to re-intubate from above.

• Prior to the use of Bovie, preoxygenate the patient to fill the FRC with reserves. Then, reduce FIO₂ to prevent airway fire.
  
• Coordinate the plan with the surgeon.
  
• Confirm trach placement with capnography and auscultation.
  
• Maintain readiness to intubate from above if the trach fails.

Your backup plan is critical. Equipment issues (disconnected ETCO₂, circuit failure) are unacceptable during this transition.