The rotation in otolaryngology/head and neck surgery offers experience in the anesthetic management of procedures in head and neck oncology, facial plastic and reconstructive surgery, laryngology, otology, sleep disorders and sinus disease. The patient population includes all ages and physical status classifications for both inpatient and outpatient surgery. Open communication between the anesthesiologist and surgeon is emphasized in preoperative airway assessment and shared access to the airway intraoperatively.
Otology: The anesthetic technique for tympanomastoidectomy and cochlear implant surgery allows facial nerve monitoring, provides an immobile field with minimal blood loss and facilitates smooth emergence. Patients receive prophylaxis for postoperative nausea and dizziness.
Sinus and sleep disorder surgeries: Patients with sinus disease benefit from adequate analgesia and prophylaxis for postoperative nausea. Drug induced sleep endoscopy, performed in the operating room or bronchoscopy suite, evaluates the sites of upper airway obstruction in obstructive sleep apnea patients during controlled sedation to assist in planning surgical intervention. Patients undergoing surgery for obstructive sleep apnea require assessment of cardiopulmonary disease, evaluation for potential airway difficulty and appropriate postoperative monitoring.
Laser surgery: CO2 laser surgery is used in the treatment of benign and malignant laryngeal disease, allowing surgical precision and hemostasis. Prevention and management of airway fires, selection of laser-safe endotracheal tubes and the application of jet ventilation are distinctive aspects of anesthesia for laser surgery.
Transoral robotic surgery: Robotic surgery offers a minimally invasive approach for patients undergoing radical tonsillectomy, base of tongue resection and supraglottic partial laryngectomy. Careful airway assessment at the conclusion of surgery identifies patients who need to remain intubated postoperatively.
Head and neck cancer with reconstruction: History, physical examination and radiographic studies determine the extent of airway distortion; further evaluation focuses on coexisting medical disease and effects of prior chemoradiation therapy. Initial airway management may require awake intubation or tracheostomy.
Oral and maxillofacial surgery: To facilitate surgical access, patients may require nasal or submental orotracheal intubation. Application of deliberate hypotension for orthognathic surgeries decreases blood loss. Patients who have sustained trauma or have soft tissue infection present for urgent surgery with a potentially difficult airway.
Airway simulation: The airway simulation program integrates lectures and hands-on training focused on adult and pediatric difficult airway assessment and management. In small group sessions residents learn to apply supraglottic airway devices, fiberoptic intubation, retrograde intubation, cricothyroidotomy and jet ventilation. Instruction with a virtual reality bronchoscopy simulator provides realistic adult and pediatric fiberoptic intubation scenarios and examples of tracheobronchial lesions. The program concludes with an objective structured clinical examination to evaluate communication, judgement and technical skills in difficult airway situations. This is a good example of subspecialty simulation in a laboratory setting. An annual cadaveric workshop offers further opportunity to practice invasive airway management techniques.
Parwane Pagano, MD
Assistant Professor of Anesthesiology at CUMC
Director of Anesthesiology for Otolaryngology/Head and Neck Surgery