Anesthesia for Middle Ear Surgery


Figure 1.

The SHANA Featured Case series offers for your attention challenging clinical cases.
Following preliminary Forum discussion, full case presentation will be provided in a
Case Report format, including comprehensive discussion with pertinent references.
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Presented by Dr. Vladimir Nekhendzy, Stanford University Medical Center.

 

Case presentation:

You are working in an ambulatory surgical center and are asked to anesthetize a 41 y.o. male patient for resection of cholesteatoma and correction of conductive hearing loss. The planned surgical procedure is left tympanomastoidectomy and ossicular chain reconstruction, scheduled for 3 hours.

Patient’s past medical history is 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 is taking Valsartan (Diovan®) 80 mg per os (PO) on a daily basis.

Airway exam revealed 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 features can be appreciated from Figure 1 (preoperative pictures of the airway exam are 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 mmHg, 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.

Discussion questions:

1.      What are the essential anesthesia requirements for otologic surgery?

2.      What is your airway management plan?

3.      How would you anesthetize this patient?

 


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