ENT Surgery

Objectives of Anesthesia for ENT Surgery

• Review functional anatomical structures of the nasopharynx, oropharynx, and hypopharynx
• Describe aspects of preoperative assessment/preparation for ENT surgical procedures
• Discuss surgical positioning for ENT procedures and the implications of a "shared" airway
• Discuss anesthesia techniques that facilitate nerve monitoring for ENT surgical procedures
• Identify various endotracheal tube designs used for ENT surgical procedures
• Develop an anesthesia management plan to address specific intraoperative needs
• Identify postoperative complications linked to ENT surgical procedures, and develop prevention/treatment plans

Objectives of Lasers for Medical Therapy and Surgery

• Review the basic principles behind the use of lasers for medical therapy and surgery
• Identify the major types of lasers used for surgery
• Discuss the effect of various laser types on target/surrounding tissues
• Discuss the implications for laser use during surgery
• Review safety recommendations to prevent injury to patients and operating room personnel
• Identify the fuel and ignition sources for surgical fires
• Describe prevention strategies for surgical fires
• Review steps required to extinguish a surgical fire and minimize injury

Head and Neck Anatomy

• Adults: Narrowest airway portion is at vocal cords
• Children: Narrowest portion is at cricoid cartilage
• Airways are similar to adults after age 10

Nerves of Head and Neck

• Facial Nerve (Cranial nerve VII) has 6 major branches: Temporal, Zygomatic, Buccal, Mandibular, Cervical, and Posterior auricular
• Injury to the facial nerve results in paralysis, affecting smiling, chewing, facial expressions, and speech.
• Trigeminal Nerve (Cranial nerve V) has 3 divisions: V1- ophthalmic, V2- maxillary, and V3- mandibular
• Trigeminal Nerve is sensory and motor for the nose, palate, and tongue and injury results in facial muscle palsy
• The Glossopharyngeal nerve (Cranial nerve IX) is sensory and motor
• It innervates the base of tongue, nasopharynx, and oropharynx
• It is responsible for eliciting the gag reflex

Nerves of Head and Neck - Vagus Nerve

• The Vagus nerve is cranial nerve X
• The Superior laryngeal branch of the vagus nerve is sensory to mucosa above the vocal cords, and motor to the external laryngeal branch-cricothyroid muscle
• The Recurrent laryngeal lies between trachea and esophagus
• It is sensory to mucosa below vocal cords and trachea
• The recurrent laryngeal branch is motor to all laryngeal muscles except cricothyroid
• Vagal stimulation can occur during intubation and ENT surgery

ENT Anesthesia - Assessment

• History includes: OSA, previous anesthetics/ENT surgeries, PONV, preexisting nerve injuries/palsy, radiation/chemotherapy, cardiac/pulmonary conditions
• Studies include: Labs (CBC, thyroid panel), X-rays (neck, chest, facial fx’s)
• Airway/Neck assessment includes: Mallampati (MP) score, range of motion (ROM), assessment for foreign body, tonsils, tumors, and trauma/swelling/fractures

Preoperative Considerations - Patient Positioning

• ENT surgery often involves a distant airway with the patient turned away from the anesthesia provider
• This necessitates clear communication between the surgeon and anesthesia team
• Protection of the established airway and prevention of hypoxia are critical
• Shared airway considerations include the surgery occurring close to the airway itself
• Maintenance of adequate ventilation, patency of the ETT, prevention of leaks, and management of throat packs are important

Positioning Issues

• Turning the patient 90 to 180 degrees away from the anesthesia machine can present challenges
• Coordination is crucial during the turn; administer 100% oxygen
• Confirm the depth of anesthesia, and administer IV anesthetic if needed
• Monitors may be disconnected
• IV lines may need extensions
• Place IV on the side of the anesthesia provider
• Circuit extension may be required

Monitoring

• Standard monitors include EKG, SpO2, RR, ETCO2, BP, Temp, NMB
• Choice of monitor placement is important
• NMB monitoring can utilize the posterior tibial nerve, similar to adductor pollicis monitoring
• NIBP cuff is typically placed on the leg
• Additional monitors/IV access include ART line, central venous pressure (CVP) via subclavian or femoral approach
• A precordial stethoscope and TEE (for monitoring air embolism) may be used

Endotracheal Tubes

• Standard ETTs are available with flexible/straight connectors
• Preformed (RAE) ETTs are available in oral/nasal/cuffed/uncuffed types
• Oral RAE is used for cleft palate repair, T&A, UPPP
• Nasal RAE is used for maxillofacial and dental cases
• Anode (armored) tubes are flexible and resist kinking
• Carden tubes allow for JET ventilation
• Microlaryngoscopy (MLT) also requires special ETTs

Nasal Intubation

• Nasal intubation is common in ENT and dental surgeries
• Vasoconstrictors like Afrin/Neosynephrine are administered to both nostrils pre-op
• Nasal trumpets with lubrication can prevent trauma
• Identify the most patent/largest nare (or away from surgical side)
• Advance NETT along the floor of the nasal passageway with steady, constant pressure
• Aggressive placement can lead to bleeding or fracture of turbinates
• An assistant can advance the NETT under guidance
• Visualize vocal cords with a laryngoscope or video laryngoscope
• Magill forceps can assist with lifting the ETT

ENT Medication Considerations

• Vasoactive medications include 4% Cocaine or Lidocaine with Epi 1:200k or 1:100k, frequently used in nasal ENT surgery
• Cocaine is an excellent local anesthetic and vasoconstrictor
• Systemic cocaine blocks uptake of epinephrine, causing tachycardia, HTN, dysrhythmias; avoid ephedrine
• Anticholinergics like Glycopyrrolate are frequently used as antisialagogues
• Glucocorticoids can reduce laryngeal edema, reduce PONV, and prolong local anesthesia
• Decadron lacks mineralocorticoid action
• PONV prophylaxis is especially important in middle ear surgery because accumulation of blood in the stomach contributes to PONV

Basic Principles of LASERs

• LASER is light amplification by the stimulated emission of radiation
• Lasers produce coherent and monochromatic light
• Laser beam photons have the same wavelength and oscillate synchronously
• This allows them to travel long distances
• Lasers can be focused to a very small area = collimation
• Laser components include an energy source, optical cavity, and lasing medium (solid, liquid, or gas)
• Lasers are named after their medium used

Medical Lasers

• Wavelength/color is determined by the lasing medium, while the effect on tissue is determined by absorption of the laser light
• CO2 laser has a long wavelength (10,600 nm) and is easily absorbed by all biological tissues, causing burns
• Lasers with shorter wavelengths absorb more poorly by water
• Lasers are matched to tissue properties: hemoglobin, melanin, and H2O are main absorbing components
• KTP and ARGON Lasers are visible and absorbed by tissue pigments

Laser Surgery

• Surgical lasers generate monochromatic light absorbed by specific tissues at different wavelengths
• Lasers emit either continuous or pulsed waves
• Common lasers are CO2 and Nd:YAG lasers
• During anesthesia, use the lowest concentration of O2
• If patient can tolerate, use FiO2 of 21%
• Although nitrous oxide is not flammable, it supports combustion
• OR personnel must wear eye protection
• A source of water should be immediately available

CO2 Laser

• CO2 laser’s long wavelength is 10,600 nm
• The beam is invisible to the human eye
• CO2 lasers are absorbed by the surface of tissues with precise and clean cut and minimum penetration of surrounding tissue
• CO2 lasers are used in resection of airway tumors
• When focused very tight, the CO2 laser can be used as a scalpel
• When defocused, the CO2 laser can be used to vaporize large areas of tissue
• Eyes should be protected with clear lensed LSE

Nd:YAG Laser

• The Nd:YAG Laser has tissue penetration of 5-7mm
• It results in tissue desiccation extending 1-2 mm around resected tissue
• It is the most powerful of medical lasers
• Poorly absorbed by water
• Well absorbed by pigmented tissue
• It is best suited for resection of bronchial and bladder tumors
• Monitor patients with laser airway surgery for 24-48 hours post-procedure
• They can cause eye damage to retina
• Protect eyes with green-lensed eye protection and requires a visible aiming beam

H0: YAG Laser

• This is a fairly new laser that has a pulsed infrared output
• Wavelength mid-infrared beam is 2070nm, with 2.1mm depth penetration
• It demonstrates excellent absorption in water rich tissues
• Uses include orthopedics and urology surgery
• Examples: Stone removal TURP
• Also used in ENT for nasal and tonsillectomy surgery

Argon and KTP lasers

• Argon is used in eye and dermatologic procedures
• It demonstrates absorption by Hgb and modest tissue penetration
• The beam is absorbed by red, orange, and yellow pigments and strongly absorbed by hgb and melanin
• Can cause retinal damage, protect with orange lenses
• KTP (Potassium titanyl phosphate) is absorbed by hgb and other pigments
• Can cause retinal damage, protect with red lenses

Surgical Fires

• Fuel sources include: Prep solutions, surgical drapes, ETT, catheters, bowel gas…
• Oxidizers include: Air, oxygen, nitrous oxide
• Ignition sources include: Surgical cautery, fiberoptic light source, lasers

Airway Fire - Signs and Actions

• Signs include darkening of ETT/soot in the circuit; orange or red glow/flames in/around the ETT
• To to stop the flow of oxidizers, disconnect breathing circuit, and remove old ETT and any other flammable material
• Pour saline into airway
• Extinguish burning ETT/LMA in basin of water
• Re-intubate with smaller ETT
• Assess extent of burns, admit patient to ICU and report fire to TJC

Laser ETT

• The ideal laser ETT should be relatively resistant to laser ignition
• No cuffed ETT or currently available ETT on the market is completely laser-proof
• Examples: Xomed, Bivona, Laser-flex by Nellcor, and Mercocel Laser-guard ETT
• ETT cuff should be filled with saline dyed with methylene blue
• Saline-soaked plegits should be placed in the airway to limit risk of ignition
• Metal foil tape wrapped around a standard ETT is best avoided

Laser Precautions

• Keep inspired O2 concentration as low as possible (21%) and avoid to nitrous oxide
• Fill ET cuff with saline (and methylene blue)
• Limit laser intensity and duration
• Place saline soaked pledgets in the airway
• Ensure a source of water is immediately available

Anesthesia Considerations - Endoscopy Procedures

• Endoscopy procedures include laryngoscopy, microlaryngoscopy, esophagoscopy, and bronchoscopy
• Often evaluating for hoarseness, stridor, or hemoptysis
• Consider foreign body aspiration, papillomatosis, tracheal stenosis, VC dysfunction, tracheomalacia/laryngomalacia
• Avoid sedatives in patients with significant upper airway obstruction or OSA
• Good muscle relaxation is essential for microlaryngoscopy
• Ensure adequate oxygenation and ventilation using small ETT, intermittent-apnea technique, or JET ventilation
• Propofol/Remifentanil drips are good choices for longer/stimulating airway cases
• IV or topical lidocaine may help blunt airway stimulation

JET Ventilation

• It is used for microlaryngoscopic and subglottic procedures when an ETT would restrict surgical access
• Requires TIVA
• Ventilation achieved with high-pressure jets of gases into the airway (up to 60 psi)
• Inspiration is accomplished by high flow of pressurized gasses; expiration is passive
• Use the lowest concentration of oxygen and monitor oxygen saturation and chest expansion
• Maintain proper TV and allow sufficient exhalation to avoid air trapping/barotrauma
• Risks include pneumothorax, subcutaneous/mediastinal insufflation, gastric insufflation, hypercarbia
• Contraindicated with an unprotected airway

Foreign-Body Aspiration

• This is a common problem in children
• Common aspirants include peanuts, popcorn, jelly beans, coins, & hot dogs
• Nuts and seeds are very common!
• Aspirants travel via the right bronchus
• Upper lobe in the supine position
• Lower lobe in the standing patient
• Complications include laryngeal edema, bronchospasm, pneumothorax, pneumomediastinum, cardiac arrest, tracheal/bronchial laceration
• Consider Foreign Body Aspiration in anesthesia management

Anesthesia Management - Foreign Body Aspiration

• Sitting position and pretreat with antisialagogue, H2 blocker, and metoclopramide
• Use spontaneous ventilation and inhalation induction and avoid mask ventilation
• Rigid bronchoscope is used by the surgeon
• TIVA is a good choice, but you can use anesthesia circuit on the side for bronchoscope
• Be prepared for emergent tracheostomy

Nerve Preservation/Monitoring

• ENT surgery may necessitate monitoring of the facial nerve, SLN, RLN, or spinal accessory nerve
• Neuromonitoring for ENT surgery may include: BAEP for acoustic neuroma surgery and intraoperative electromyogram (EMG) used for facial and recurrent laryngeal nerve
• NMB agents can be given on induction but must be reversed before monitoring
• Local anesthetics can suppress muscle movement and are contraindicated
• Short-acting potent opioids like Remifentanil minimize movement during surgery

Ear Surgery

• Surgical types include tympanoplasty, stapedectomy, mastoidectomy, cholesteatoma removal
• Mask anesthesia is used for BMT in pediatrics
• A motionless surgical field requires the use of a surgical microscope and is preferably bloodless
• May use muscle relaxants if the facial nerve is not being monitored
• Minimize blood loss with topical Epinephrine
• Prevent HTN with Dexmedetomidine, Esmolol, Remifentanil, IA, and Magnesium sulfate
• Middle ear surgery results in postop N/V and vertigo
• Avoid coughing and bucking at the end of surgery; consider deep extubation
• Nitrous oxide has dose-dependent increases in middle ear pressures
• It should be avoided in major ear surgeries such as tympanoplasty, mastoidectomy, and cochlear implants
• Safe to use in BMT

Mryingotomy and Ventilating Tube Insertion

• Indications include chronic serous otitis media (Pneumococcus, H influenza, and Streptococcus, Mycoplasma pneumoniae)
• General mask anesthesia
• Pressure equalization (PE) tubes are inserted under a myringotomy in the tympanic membrane
• Manages chronic middle ear infections when antibiotics are no longer effective
• Allows drainage of serous infected material
• Eustachian tubes connect middle ear to nasopharynx
• Adenoids are in the nasopharynx close to opening of Eustachian tube, and/or may be the cause
• Possible to have day of surgery URI

Anesthetic Management for Bilateral Myringotomy Tube (BMT)

• It is a brief procedure, usually performed in outpatient setting
• Oral midazolam outlasts surgical procedure
• Mask induction (volatile + N2O) + maintenance of GA
• N2O helps the surgeon
• Usually require no IV access

Anesthetic Management Post Bilateral Myringotomy Tube (BMT)

• Treat with Postoperative analgesia such as: -Tylenol PO 10-20 mg/kg -Rectal 30-40 mg/kg -Intranasal Fentanyl 1-2 mcg/kg -IV Toradol 1 mg/kg -Intranasal Butorphanol (Stadol) 25mcg/kg -Intranasal Dexmedetomidine 1-2 mcg/kg

Anesthetic Management of Middle Ear and Mastoid Surgery

• Chronic untreated ear infections invade the mastoid cells in the bone adjacent to the ear canal, causing openings in the bony mastoid process for drainage which requires a mastoidectomy
• Cholesteatoma is a growing mass of epithelium/bacteria that results in chronic infection, destroying the ear ossicles, leading to hearing loss
• Middle ear reconstruction can require revision or replacement of some or all of the ossicles
• Avoid NMBs because facial nerve monitoring is important because a branch of it passed through the ear canal.
• Surgeon may require controlled hypotension
• Ensure gentle emergence

Anesthetic Management of Tympanoplasty Surgery

• N2O diffuses into the air-filled space in the middle/inner ear, causing expansion of the tympanic membrane
• Tympanoplasty involves grafting material onto a new tympanic membrane reconstruction (often traumatic rupture, removal of retained PE tubes, or middle ear reconstruction)
• N2O can dislodge the graft, which must be confirmed by the surgeon if it should be avoided!
• N/V occurs frequently, and treated with premedication antiemetics like decadron and zofran
• Aim for a smooth, deep extubation with lidocaine to avoid bucking and coughing

Tonsillectomy

• Adenoids/tonsils shrink in size after puberty since they are both lymphoid tissues
• Adenoidal hypertrophy can obstruct the eustachian tube, which can result in middle ear disease
• Recurrent tonsillitis and tonsillar hypertrophy can produce airway obstruction, can cause snoring, sleep apnea, hypoxia
• Kissing tonsils involve hypertrophy and contact each other at the back of the oral cavity

Tonsillectomy and Adenoidectomy

• This is often performed on an outpatient basis
• Some patients are not suitable for ambulatory surgery on the tonsils
• Must consider younger than 3 years old children
• Review History of coagulopathy, significant OSA, other significant systemic disease such as CHD, neuromuscular/endocrine, chromosomal abnormalities, Craniofacial/airway abnormalities, history of peritonsillar abscess

Tonsillectomy and UPPP

• Considerations for airway obstruction, shared airway, mechanical suspension of airway, rapid awakening, OSA, and redundant pharyngeal tissue
• Use Oral RAE ETT with a gag insertion and turn table around 45-90°
• Goals of anesthesia revolve around deep level of comfort to blunt reflexes from stimulation
• Rapid return of protective reflexes that include postop analgesia
• Reduced bleeding while focusing of minimal PONV
• Reduce postop N/V incidence by suctioning stomach at the end of surgery
• Reducing coughing by using with IV Lidocaine upon emergence
• Extubate patient awake
• After surgery transport to PACU in side-lying position with head down
• The most common complication after tonsillectomy is postop bleeding
• Post UPPP, the most common complication is airway obstruction secondary to swelling

Post Tonsillectomy Bleed

• This is a surgical emergency
• Primary occurs within 6-24 hrs
• Secondary occurs 5-10 days postoperatively
• Most common in pts > 15 yrs, boys, frequent tonsilitis, after use of electrocautery technique
• These patients are considered full stomachs for which you treat with rapid sequence intubation while applying cricoid pressure and the patient is in an awake extubation.
• The stomach contains blood, which can be regurgitated during induction and hypovolemia may be present following correction of severe anemia.
• Provide sufficient fluids and ensure awake extubation

Airway Abscesses

• Airway Abscesses should be identified
• Ludwig's Angina if the patient has it, should too.

Sinus and Nasal Surgery

• Common surgical includes polypectomy, FESS, rhinoplasty, septoplasty
• Patients with chronic sinusitis have an increased incidence of Reactive Airway Disease: Samter’s Triad (nasal polyps, asthma, and ASA allergy)
• Mucous membranes of sinuses and nose are highly vascular
• Epinephrine soaked pledgets shrink nasal mucosa decreasing intro-op blood loss
• Often added to LA injection to prolong action
• Systemic uptake of epi may cause increase HR and BP
• Consider Cocaine 4% which is can be used as LA and vasoconstrictor that blocks reuptake of NE/Epi
• Tape patient’s eyes closed to prevent corneal abrasion, exception with FESS cases because it's not recommended
• Suction stomach to remove any blood and secretions for Smooth, awake extubation with return of protective reflexes
• Caution the patient by avoiding coughing at the end of surgery

Thyroid Surgery

• Surgical treatment includes a surgecial treatment for a thyrotoxicosis or malignant tumor of thyroid gland
• Prep efforts should include a patient that has goals as for 1) euthyroid
• 2. assess organ and 3) assess airway
• Give glucocorticoiods, beta-blockers, and antithyroid medications: Carbimazole, Propylthiouracil, Iodide, Methimazole, Lugol’s solution as a Preoperative medications
• Use a thyroid panel- low TSH, high T3, high T4 to assess patient

Thyroid Surgery - Pre Op

• Do preop testing along with a CT scan for larger goiters to rule out if there might be an airway compression
• Check the EKG in cases of cardiac dysfunction
• Assess the airway and breathing in supine position to rule out airway compromise, this way it doesn't worsen the symptoms.

Thyroid Surgery Planning During Anesthesia

• During the operation, it would be ideal to avoid muscle relaxants after induction to properly allow for nerve monitoring
• Protect eyes with eye shields when approaching the Shared surgical space around head/airway
• Have the Head elevated 30 degrees w/ neck extension and tuck the Arm as necessary to limit with access to both IV, BP cuff.
• When doing a Recurrent laryngeal nerve monitoring common for thyroid and doing a parathyroid surgery it gives results of Injury results in vocal cord dysfunction such as hoarseness or aphonia

Thyroid Surgery Actions Intraop

• NIM ETT use will assist to assess the function of the RLN during traction
• 4 wires inbeded in ETT above cuff to help them touch the vocal cords, with those actions, function of both left and right RLNs can be properly detected
• Use Intraoperative maintenance when using an IA with/without nitrous oxide while also avoiding the use of ephedrine should be the goal so use Deep/superficial plexus block for postop pain post operation.
• https://youtu.be/aDoUbTQ3QlE assist in understanding NIM Endotracheal Tubes

Thyroid Surgery Actions PostOp

• In post operative state, the potential concern is Hypocalcemia by assessing if the patient had any parathyroid with a “stunned”

• Check for neuronal excitation that might be confirmed by signs such as Chvostek’s and Trousseau’s

• Recurrent laryngeal nerve injury may occur with its side effect unilateral

• In a situation with bilateral injury, both remain midline during inspiration and stridor

• There is potential for Hematoma formation which causes Neck swelling, dyspnea

• Ensure you can provide access the patient with Emergent evacuation of hematoma in the rare chance they require one.

Head and Neck Cancer Surgery

• Potential need for Glossectomy if in a situation of pharyngectomy and laryngectomy that might parotidectomy, neck dissections
• Patient typically involves is elderly and have a long medical history with tobacco
• Co-morbidities to consider include COPD, CAD, HTN, diabetes, chronic alcoholism, aspiration pneumonia, malnutrition
• Airway management is essential
• Mask ventilation happens before administering paralytic or trying to complete direct/FO laryngoscopy
• Having or preparing to do tracheostomy is crucial
• Take note to avoid extra caution is warranted in post radiation therapy pts!
• All equipment must fit properly - Large-bore IVs, arterial line, possible central line, foley, Bair hugger

Controlled Deliberate Hypotension

• Potential for significant blood loss with extensive head and neck dissections for tumors, or maxillofacial reconstructive surgeries
• Usually reduce MAP to range of 60-65 mm Hg
• Combination of inhalation agents, alpha blockers, calcium channel blockers, IV agents directly blocking arterial tone
• SNP, Esmolol, NTG, Nicardipine, Fenoldopam
• Monitor mean arterial pressure, UOP, and ABGs closely
• Slight head up position

Intraerative Tracheostomy Actions

• After dissection down to trachea, ETT cuff deflated to avoid perforation by scalpel
• Tracheal wall transected, ETT withdrawn until tip is cephalad to incision in hopes for an effective ventilation, there will be difficultly d/t the large leak through trachea
• Ensure patient is provided with Sterile, wire-reinforced ETT that is placed in trachea and sutured to chest wall
• After confirm, you can remove old ETT after proper placement by capnography and lung sounds can be heard.
• Increase in PIP after tracheostomy usually means a malpositioned tube so evaluate the patient for possiblebronchospasm, or debris in trachea for any mal-functions during the procedure

Head and Neck Cancer Surgery

• Manipulation and infiltration of the carotid sinus with LA usually alleviates this problem
• The right side of the dissection in manipulation is often what is completed more than the left.
• This allows for stabilization of swings in in BP, reducing bradycardia, dysrhythmias, reduce chance forSinus arrest, and prolonged QT intervals
• If there is dissection on both side, Bilateral, the potential risk is for hypertensive post op issues caused by denervation of the carotid sinuses and bodies

Craniofacial Reconstruction and Orthognathic Surgey

• All situations whereLeFort fractures/osteotomies, congenital malformations, radical cancer surgery, mandibular osteotomies need consideration and use Throrough preop airway evaluation
• Key things to check are jaw opening, mask fit, neck mobility, micrognathia, retrognathia, maxillary protrusion, macroglossia, dental pathology, nasal patency
• In the worst case scenario, it is best to be prepared and resolve Potential mask ventilation/ETT problems. It is ideal and to secure airway prior to induction
• To assist in minimizing future complications, it is best to the surgeon about possibly not proceeding past where LeFort II or II fractures

Craniofacial Reconstruction and Orthognathic Surgery Actions

• These types of procedures have risk factors with Potential for substantial blood loss so control the patient to have a smooth sustained controlled hypotension and administer a combination with epinephrine solutions

• If there is an insertion of a patient with substantial blood, often times the best strategy would be an Oropharyngeal pack that will minimize blood and debris from reaching the larynx and trachea

• Evaluate postop edema to see any potential structures you can obstruct, and it is ideal to leave patient intubated rather than allow airway loss.

• After extubation, do so when fully awake and no signs of continued bleeding will be assessed.

• All patients with maxillomandibular wiring should have wire cutters at the bedside in case of vomiting/airway emergency

Cleft Lip and Palate

• These are known congentical malformations
• Male is more likely to sustain issues > Females, it is due to a issue related to Folate metabolism disorder
• There are also potential Chromosomal abnormalities (1,2,4,6,14,17,19)
• This often causes a common list of situations such as Pierre Robin Sequence, Down Syndrome, Treacher Collins Syndrome, Fetal Alcohol Syndrome, and Goldenhar Syndrome

Cleft Lip and Palate Repair

• Surgery is broken in to increments such as 3 months when a cleft lip is repaired, 6 months of when the cleft palate is repaired, early is for surgery of lip or nose revision. When the patient turns 10 years, they would undergo a palatal revision/ bone graft procedure and rhinoplasty and maxillary osteotomy would then be completed between the ages of 17 - 20 years old.
• These procedures have minimal blood loss and will only see any possiblity for Airway difficuties in roughly 4.7 - 8.4% of all patients.

Cleft Lip and Palate Planning

• If you do expect a challenging procedure it is ideal to use a Mask induction (if it is usually uncomplicated). Consider using a blade or Laryngoscopy with a Miller blade.
• It is important to avoid inserting the blade into the cleft and understand there is a chance you may not be intubate most children unless there are other defects present. It is an Oral RAE (if present) and is is usually 1-2 hrs procedure. In cleft palate repair, the pharyngeal space is significantly reduced, plan to extubate the patient wide awake.
• There is risk for upper airway obstruction from sources like airway narrowing, edema and/ blood.
• Plan for other complications such as late post edema and severe

Subcutaneous emphysema.

• These will often also be accompanied by Postoperative pain, so assist in alleviating it with analgescs such as a dose of Tylenol and Opioids.

Funcitonal Endoscipic Sinus Surgery Planning - FESS

• Review that FESS is a standard and effective surgical treatment for for sinus
• Assist in Precse resection to improve a and restore nomality of mucosa function . It is key to assess for the patient to have any previous that Liberal use of vasoconstrictors with rhink edematous in attempts to alleviate and ensure doses are not exceeded . There is one main Functional Endoscopic Surgery related issue and it is if patient has any bleeding
• A small percentage group may require packing the area where bleeding . During tape off, a great idea may be to and have lacribube nearby so the patient has a easier time waking . Check for Rupture through any bony of sinusis during the scope proedure . Often seen asPeriorbital and the worst cases swelling . Common Patients who have history with CF are more likely to have this type of
• In terms of monitoering its a must to ensurepulmonary and any signs ofdepression.

Trauma Considerations in Procedures

• This the the major final consideratations during various procedures. Begin to review airway based and make sure to assess the patient of Severe if they have , or JET
• To avoid potential damages or harm in procedures during the most
• Possible injuries to be the number one thing that has to be avoided awake the
• This might require a RSI technique procedure.