Anesthesia for Middle Ear Surgery (Preview)

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Figure 1

 

 

Presented by Dr. Vladimir Nekhendzy, Stanford University Medical Center.

 

 

Case presentation:

Some time ago we offered for your attention a challenging case  of a 41 y.o. male patient who had presented for resection of cholesteatoma and correction of conductive hearing loss (Figure 1). The planned surgical procedure was left tympanomastoidectomy and ossicular chain reconstruction, scheduled for 3 hours in the ambulatory surgical center.

The patient’s past medical history was significant for morbid obesity (MO; height 190 cm, weight 161.4 kg, BMI 44.7 kg/m2), snoring, severe obstructive sleep apnea (OSA) treated by CPAP, systemic hypertension (HTN), and absent symptoms of gastroesophageal reflux disease (GERD). The patient had no drug allergies, and was taking Valsartan (Diovan®) 80 mg per os (PO) on a daily basis.

Airway exam revealed a short, thick neck (neck circumference 54 cm), decreased oral entry (small mouth), big tongue, Mallampati (MP) III grade, normal mandibular protrusion, and thyromental distance of 6 cm. Some of these airway features could be appreciated in Figure 1, above (preoperative pictures of the airway exam were not available). The rest of the airway exam was normal, and physical exam was otherwise unremarkable.

Preoperative ECG demonstrated mild left ventricular hypertrophy; laboratory tests were within normal range. The patient had normal exercise tolerance. Preoperative vital signs were: NIBP 147/95 mm Hg, heart rate 86/min, respiratory rate 20/min, SpO2 96% on room air. On the day of surgery, the patient had been NPO for over 6 hours.

The following questions were offered for discussion:

  1. What are the essential anesthesia requirements for otologic surgery?
  2. What is your airway management plan?
  3. How would you anesthetize this patient?

We are now happy to share with you some of the answers of the SHANA Education and Scientific Boards members, followed by presentation and discussion of the actual case management...

 

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