Local anesthetics for facial plastic procedures.

The use of local anesthetic in facial plastic surgical procedures is well established as an effective and safe mode of anesthesia delivery. Local infiltration of anesthesia may be used alone for minor surgical procedures, or it may be used with general anesthesia or intravenous sedation and analgesia for more complex, lengthy procedures. When considered independently, the use of local anesthetic agents has undeniable limitations. Local anesthetics can cause toxicity and side effects. Injection of local anesthetics for subcutaneous infiltration frequently is painful until sensory anesthesia occurs. Local anesthetics have limited efficacy with respect to the intensity and duration of sensory blockade that can be achieved. In some situations, use of local anesthesia with the maintenance of an awake patient also may be undesirable for the surgeon and impractical for the patient. Despite these shortcomings, local anesthetics are fundamentally ideal for use in facial plastic surgery.     

Quality of recovery and safety of deep intravenous sedation compared to general anesthesia in facial plastic surgery: A prospective cohort study

BackgroundFacial plastic surgical procedures are performed under either general anesthesia (GA) or sedation. GA is often associated with post-operative nausea and longer recovery, while deep sedation is thought to greatly facilitate perioperative patient comfort and expedite recovery. The objective of this study was to compare these two anesthetic techniques in a relatively healthy patient population undergoing facial plastic surgery and to discuss optimizing patient safety with a deep sedation technique.MethodsA non-randomized, prospective cohort study was conducted to evaluate patients undergoing facial plastic surgery with a focus on rhinoplasty under either deep intravenous sedation (DIVS) in an ambulatory surgery center or under GA in a community hospital. Patients were between ages 18–65 and agreed to participate in the study and complete a quality of recovery (QoR-40) survey. Two-tailed Student's t-test was done for numerical data and Chi-squared test for categorical data.ResultsTwenty-three patients and 16 patients had surgery under DIVS and GA, respectively. Compared to the GA group, the DIVS group had less post-operative nausea and vomiting (21.7% vs 50%, P = 0.04; 4.3% vs 37.5%; P = 0.004, respectively), shorter emergence time (4 vs 13 min, P < 0.001), and higher QoR-40 scores for almost all the categories except for physical independence. There were no post-operative medical or surgical complications.ConclusionDIVS appeared to be safe in the office-based setting and provided a higher quality recovery after a predominantly rhinoplasty-based practice compared to the GA group. Vigilant monitoring of the patient is crucial for careful titration of sedation to avoid respiratory depression and possible compromise of the surgical result from having to rescue the airway.     

Neurolept analgesia in ambulatory (nasal) endoscopies.

Neurolept analgesia in ambulatory nasal endoscopies has been gaining widespread use recently. Scrupulous selection of patients and careful preoperative evaluation and premedication are essential. Excellent surgical block is a prerequisite to good neurolept analgesia. Versed (midazolam) is particularly suitable for outpatient surgery, since it provides superior operative condition to Valium (particularly less venoirritation) and rapid recovery in the postoperative period associated with a low incidence of nausea and vomiting. When used in combination with fentanyl (Sublimaze) or alfentanil, Versed is suitable for the provision of total neurolept analgesia. Careful intraoperative vigilance and monitoring, including pulse oximetry, cannot be overemphasized.     

鼻内镜下经蝶窦入路垂体肿瘤切除术的麻醉选择

目的：探讨在鼻内镜下经鼻腔蝶窦垂体肿瘤切除术的麻醉方法。方法：在鼻内镜下经鼻腔蝶窦入路切除垂体肿瘤56例,其中8例在全身麻醉下完成,48例局部麻醉加基础麻醉下完成。结果：所有患者都顺利完成手术,56例均无手术并发症,其中在局部麻醉加基础麻醉下完成的48例,术中出血量明显减少,生命体征平稳,无呻吟挣扎,手术顺利。结论：局部麻醉加基础麻醉下行鼻内镜下经鼻腔蝶窦垂体肿瘤切除术简单、安全,且效果好。     

Indirect Larynx and Pharynx Surgery: A Replacement for Direct Laryngoscopy

During a 2-year period, 192 indirect surgeries on the laryngopharynx were performed in an outpatient videoendoscopy laboratory under topical anesthesia with or without intravenous sedation. These procedures included cancer staging and biopsy; vocal fold injections of Teflon, Gelfoam, botulinum toxin, or steroids; glottic web lysis; and granuloma removal. The techniques used to perform these procedures are elucidated. Careful chart review of these patients shows that indirect surgery was performed successfully in 96% of cases. Intravenous conscious sedation was utilized in 39% of patients. No significant complications were encountered. By avoiding the need for an operating room, hospitalization, or general anesthesia, this technique was clearly as safe or safer, more convenient for surgeon and patient, and more cost-effective than the same procedure would have been via the traditional direct laryngoscopy. As the authors have already done in their practices, the indirect method should therefore be reinstated as the preferred approach to the clinical circumstances described here. Laryngoscope, 106:1280-1286, 1996     

Clinical utility of local over general anesthetic tonsillectomy using the BiZact™ device

PurposeTonsillectomy under general anesthesia may be viewed preferentially to local anesthesia, due to mitigation of potential airway compromise secondary to intraoperative hemorrhage, patient discomfort and anxiety. However, this is offset by risk of increased trauma (via the endotracheal tube and gag), adverse medication reactions and cost. Here we evaluated the case for use of local anesthesia in tonsillectomy using the BiZact? (Medtronic) device by comparing surgical outcomes and cost factors across patients where either local or general anesthesia was employed.Materials and methodsRetrospective cohort study of 59 BiZact? tonsillectomy patients (38 under local anesthetic, and 21 under general anesthetic) from a single surgeon at Tauranga Hospital (public) and Grace Hospital (private) in New Zealand; March 2018 to June 2021.ResultsNeither patient group had any primary postoperative hemorrhage and there was comparable incidence of secondary hemorrhage (one case in each cohort). Local anesthetic tonsillectomy was well tolerated with only 2 patients requiring conversion to general anesthetic secondary to anxiety. Local anesthetic proved to be cost-effective, with a halving of hospital length of stay and significant associated overall cost saving, and did not add significantly to operating or total theatre time. Local anesthetic tonsillectomies where perioperative sedation was not required were associated with additional reductions in recovery and overall hospital stay, and cost.ConclusionsLocal anesthetic BiZact? tonsillectomy is evidently safe and cost-effective.     

Experience harvesting costal cartilage under IV sedation

ImportanceWhile numerous techniques for costal cartilage harvesting have been described, one consistency in the published literature is that the procedure is performed under general anesthesia. This is the first report to offer IV sedation as a safe alternative to general inhalational anesthesia in cases involving costal cartilage harvesting.ObjectiveTo determine the feasibility and safety of costal cartilage harvest with IV sedation.DesignA retrospective chart review was performed of 116 rhinoplasty patients who underwent harvest of costal cartilage grafts under IV sedation from 2005 to 2019.SettingPrivate practice of senior author (AF) at Lasky Clinical Surgical Center.ParticipantsConsecutive patients who underwent cosmetic and/or functional rhinoplasty.Main outcome & measuresThe number of cases involving a pneumothorax, size of the pleural injury, radiographic findings, repair technique and treatment for pneumothorax were all recorded.ResultsThere were 7 cases involving a pleural tear (size range 3-8 mm) during costal cartilage harvest and each of these was repaired intra-operatively. All 7 patients remained clinically stable in recovery room on 2 L of oxygen. Although clinically stable, one patient had radiologic evidence of a pneumothorax of 50%, and thus she was transferred to a hospital for placement of a Heimlich tube with overnight observation.Conclusions and relevanceAlthough plenural tears can be attributed to surgical technique rather than the type of anesthesia, these cases do provide valuable insight to the fact that successful management of such complications can be accomplished without the need for general anesthesia.     

The effect of the total intravenous anesthesia compared with inhalational anesthesia on the surgical field during endoscopic sinus surgery

BACKGROUND: Bleeding during endoscopic sinus surgery (ESS) may increase complications and negatively effect the surgery and its outcome. The aim of this study was to compare the surgical field in patients in whom total intravenous anesthesia (TIVA) is used as opposed to inhalation anesthesia. A prospective randomized controlled trial was performed. METHODS: Fifty-six patients undergoing ESS were randomly assigned to receive either inhaled sevoflurane with incremental doses of fentanyl (n = 28) or TIVA via a propofol and remifentanil infusion (n = 28) for their general anesthesia. The surgical field was graded every 15 minutes using a validated scoring system. RESULTS: The two groups were matched for surgical procedure and computed tomography scores. Patients in the TIVA group were found to have a significantly lower surgical grade score than in the sevoflurane group (p < 0.001). Surgical grade score increased with time in both groups. Mean arterial pressure and pulse were found to influence the surgical field independently (p = 0.003 and p = 0.036 respectively). Mean surgical field grade scores were higher in the patients with allergic fungal sinusitis and nasal polyposis as opposed to chronic rhinosinusitis without polyps or fungus. Lund-Mackay computed tomography scores were found to correlate positively with surgical grade (Spearman rank correlation, p = 0.001). CONCLUSION: In patients undergoing ESS, TIVA results in a better surgical field than inhalational anesthesia.     

Anesthetic techniques for pharyngeal flap surgery: effects on postoperative complications.

OBJECTIVE: To assess the effects of 2 different anesthetic techniques on early complications after superior pharyngeal flap surgery. DESIGN: Randomized, prospective, single-blind study. SETTING: Large referral hospital. PATIENTS: One hundred patients undergoing superior pharyngeal flap surgery for the correction of velopharyngeal insufficiency were randomly divided into 2 equal groups to receive either isoflurane or propofol-based anesthesia. INTERVENTIONS: Following induction of anesthesia with fentanyl citrate and propofol, patients were randomized to receive either isoflurane or propofol for the maintenance of general anesthesia. The inspired isoflurane concentration and propofol infusion rate were adjusted to maintain a stable depth of anesthesia as judged by clinical signs and hemodynamic responses to surgical stimuli. MAIN OUTCOME MEASURES: Recovery from anesthesia, recovery from surgery, and early postoperative complications. RESULTS: The groups were similar in age, weight, height, induction time, surgery time, extubation time, and anesthetic time. The time (mean +/- SD) required to achieve a maximal Steward Recovery Score was 7 +/- 14 minutes in the propofol group compared with 32 +/- 28 minutes in the isoflurane group (P<.04). No significant differences in postoperative patient satisfaction scores, time to first swallow, drinking time, and time to "home readiness" were noted. Overall, 17 patients (17%) developed airway-related complications and 2 of the patients (2%) were accounted as severe. Two patients (2%) bled from the operation site. However, there was no difference in the incidence of postoperative complications between the groups. CONCLUSIONS: When compared with isoflurane administration for maintenance of general anesthesia, propofol-based anesthesia was associated with more rapid mental and psychomotor recovery. However, airway-related complications and "home readiness" were similar between the groups.     

Combined local anesthesia and monitored anesthesia care for cochlear implantation

IntroductionCochlear implantation has become a routine procedure for patients with hearing loss. In some patients, general anesthesia might be contraindicated due to multiple co-morbidities. We describe a successful protocol for cochlear implantation under local anesthesia with light sedation.Case reportAn 81-year-old patient presented with profound sensorineural hearing loss. Her past medical history revealed ischemic coronaropathy, managed by stenting. After multidisciplinary evaluation and clear adapted information to the patient, surgery was performed under local anesthesia with light sedation and monitored anesthesia care. The procedure lasted 70 min, and was without incident and under good conditions for the surgeon. During the intervention, the patient was comfortable. No nausea or vomiting was noted. The postoperative period was smooth and uneventful.ConclusionWe find local anesthesia with light sedation a good alternative to general anesthesia for patients where general anesthesia is contraindicated. An experienced surgical and anesthesiology team is essential to shorten the duration of the procedure.     

Needle aspiration as primary surgical treatment of pediatric deep neck space abscesses

ObjectiveExamination of the outcomes of needle aspiration (NA) under sedation as the primary surgical treatment for pediatric deep neck space abscesses (DNSA) to determine its adequacy, safety, and cost.Study designRetrospective chart review.Methods10 consecutive pediatric patients (age 4–48 months) that were diagnosed with DNSA starting from August 2008 through October 2015 were included in our review. All patients were on antibiotics and were treated with NA as the primary surgical treatment modality. Procedures were all performed in our pediatric sedation suite. We have examined our outcomes including need to convert to open incision and drainage (I&D), number of aspirations required, hospital stay, if purulence obtained, culture results, and imaging modality used. We also compared our results with previous studies using incision and drainage as the primary treatment modality focusing on the duration of their hospital stay.ResultsNone of our 10 patients required an open I&D. Two of 10 (20%) did require repeat aspiration once with no patient requiring more than two aspirations. Median hospital stay was 4 days (range 3–8).ConclusionIn our small study group NA performed under sedation was an effective treatment modality with duration of hospital stay comparable to other studies that included treatment with I&D under general anesthesia.     

Recovery of the horizontal vestibulo-ocular reflex in motorized head impulse test is common after vestibular loss

Conclusion: Retroauricular tympanoplasty and tympanomastoidectomy under local anesthesia with sedation can be well tolerated by the patient, with minimum discomfort. Objectives: To evaluate patient discomfort from pain, body/neck position, noise, and anxiety during tympanoplasties and mastoidectomies performed under local anesthesia with sedation. Patients and methods: This was a prospective study of 83 surgeries in 62 patients (28 type I tympanoplasties, 12 tympanoplasties with ossicular reconstruction, 40 canal wall up mastoidectomies, and 3 revision tympanoplasties). Local infiltration used lidocaine 2% with 1:100 000 epinephrine infiltrated in the retroauricular area and from below the pinna in a ‘V’ pattern. Sedation was achieved with 50 mg of intramuscular promethazine 1 h before surgery and intravenous midazolam (0.03 mg/kg) at the beginning of surgery. Subsequent doses of midazolam were given to maintain adequate sedation, up to 10 mg. The discomfort during surgery was assessed by the patient with a score from 0 to 4 (0=no discomfort and 4=extreme discomfort). Results: Discomfort due to pain had a mean score of 0.83. Noise discomfort (from drilling and manipulation of instruments) had the lowest mean score (0.70), and discomfort from body and neck position had the highest mean score (1.51).     

Ketoprofen and fentanyl for pain after uvulopalatopharyngoplasty and tonsillectomy

OBJECTIVES: The treatment of postoperative pain after uvulopalatopharyngoplasty (UPPP) and tonsillectomy presents a challenge. Opioids can cause sedation and respiratory depression. Nonsteroidal antiinflammatory drugs can increase postoperative bleeding. The authors have evaluated the severity of postoperative pain and the consumption of opioid in 53 adult patients undergoing either UPPP or tonsillectomy. STUDY DESIGN: A prospective, parallel-groups study. METHODS: A general endotracheal anesthesia was used in each patient. After surgery patients received ketoprofen 1 mg/kg as an intravenous bolus, followed by a continuous infusion of 4 mg/kg during 24 hours. For rescue analgesia patient-controlled intravenous fentanyl was used. RESULTS: Both UPPP and tonsillectomy are associated with intense postoperative pain. More than 40% of the patients had high pain scores during the first 24 postoperative hours. Postoperative pain after UPPP was more severe and the difference was significant during swallowing (P < .05). The need for fentanyl in the UPPP group was twice that of the tonsillectomy group (P < .01). There was a high interindividual scatter in the patient-controlled fentanyl attempts in both groups. The patients in the UPPP group needed significantly more oxygen supply during recovery (P = .007). No serious adverse effects occurred and none of the patients experienced postoperative bleeding that required any intervention. CONCLUSION: Individually tailored analgesic treatment protocol is essential for patients undergoing UPPP and tonsillectomy to ensure safe and effective pain alleviation.     

Aktueller Stellenwert der ambulanten Chirurgie in deutschen HNO-Kliniken

Aim

German ENT clinics currently do not attach great importance to outpatient surgical procedures. However, up-to-date data on the proportion of outpatient surgeries are not yet available.

Materials and Methods

In a retrospective study, outpatient surgical procedures using anesthesia or sedation at a German ENT clinic were analyzed as an illustrative case study.

Results

In 2010, the proportion of outpatient surgeries performed under anesthesia or sedation in relation to the total number of surgeries performed under anesthesia or sedation was no more than 3.1%. Although a broad range of surgeries was offered, mainly adenoidectomies were carried out.

Discussion

In view of the increasingly limited financial resources in the German health care system and considering the situation in international health care systems, the significance of outpatient surgical procedures in ENT clinics is expected to increase in the future. Future-oriented clinic organization should therefore include sufficient capacity for outpatient surgeries. The basic requirement is realistic cost reimbursement by the insurers.     

Stapes surgery for otosclerosis under local anaesthesia with sedation

The stapes surgery surgical technique has now been clearly standardized, ensuring a reliable and reproducible procedure with a satisfactory success rate. The possibility of performing this surgery under local anaesthesia with sedation requires very good collaboration between surgeons and anaesthetists. The patient is informed about the various steps of the operation to ensure that he or she is reassured both before and during the procedure. Local anaesthesia with sedation constitutes an alternative in patients afraid of general anaesthesia. Sudden onset of dizziness reported by the patient during the operation after piston placement may be due to an excessively long piston, which may need to be adjusted. We describe the technique used in our centre. In the literature, there is no difference in terms of audiometric performance and dizziness between patients operated under local anaesthesia with sedation or general anaesthesia.     

The value of fentanyl/diazepam anesthesia for experimental operations

Summary Fentanyl/diazepam anesthesia is an appropriate combination for surgical operations on the guinea pig, since it ensures definitive anesthesia and analgesia without respiratory depression. Comparative investigations with pentobarbital and urethane were carried out to check their applicability for electrocochleographic recordings. We found that fentanyl/diazepam combination anesthesia is more suitable for electrocochleographic investigations than pentobarbital. We were thereby able to prove that pentobarbital has an attenuating effect on electrocochleographic recordings in contrast to the findings reported in the available literature. For this reason, and because the lowest rates of animal morbidity occurred with fentanyl/diazepam, this combination anesthesia should be used preferentially for electrophysiological experiments in guinea pigs.     

Otosclerosis surgery under local anesthesia with sedation: Assessment of quality of life and stress

ObjectivesThe main study endpoint was tolerance of stapedotomy under local anesthesia with sedation and under general anesthesia using stress and quality of life assessment questionnaires. Secondary endpoints comprised operative time and functional results.Material and methodIn a consecutive series of stapedotomy patients operated on over a 12-month period, quality of life and perioperative stress were analysed by 3 questionnaires: the Glasgow Benefit Inventory, Cohen's perceived stress scale and the Post-traumatic stress disorder checklist scale. Questionnaire responses and audiometric data were compared between groups treated under local anesthesia with sedation and under general anesthesia.ResultsTwenty-two patients were included in the local anesthesia with sedation group and 6 in the general anesthesia group. There was no difference between the groups for quality of life, onset of post-traumatic stress, or perceived pre- and postoperative stress. There was also no difference in operative time. The audiometric data confirmed the reliability of stapedotomy. Stapedotomy under local anesthesia with sedation improved air conduction with ≤ 10 dB air-bone gap (ABG), comparable to results under general anesthesia. The rate of ABG ≤ 10 dB was 71.4%; no labyrinthisation was observed.ConclusionUnder local anesthesia with sedation, stapedotomy was well tolerated without increasing the stress associated with otosclerosis surgery. By correcting hearing loss, the procedure improves quality of life.     

全身麻醉对小儿听性脑干反应测试结果的影响

目的 研究应用听性脑干反应(auditory brainstem reaction，ABR)作为监测小儿全身麻醉深度与觉醒的客观指标。方法 选择听力正常的外科择期手术患儿45例，按照美国麻醉学家学会表针分为I～Ⅱ级，分别施行异丙酚静脉麻醉、芬太尼静脉麻醉及异氟醚吸入全身麻醉，随机每组15例，应用丹麦Madsen诱发电位反应仪监测并记录麻醉各阶段ABR的I、Ⅲ、Ⅴ波潜伏期及I-Ⅲ、Ⅲ-Ⅴ、I-Ⅴ波间期，研究观察潜伏期和波间期随时间推移及麻醉剂量变化之间的关系，探讨ABR在异丙酚、芬太尼及异氟醚等不同麻醉中的表现特征和规律。结果 ①异丙酚静脉麻醉和异氟醚吸入麻醉与剂量呈良好的正相关；②I波的潜伏期特性对于控制麻醉深度极为重要；③Ⅴ波监测麻醉具有最佳的稳定性及相关性；④停用麻醉药一段时间或患儿基本清醒时，ABR各波潜伏期和波间期有的仍高于正常值，这是滞后(延迟)反应；⑤ABR对芬太尼术中的觉醒监测不太敏感。结论 ABR各波的潜伏期及波间期变化，可判断小儿全身麻醉深度，在一定程度上可作为判断觉醒的参考，但应考虑有延迟反应的可能。     

颈淋巴结转移癌的氩氦靶向治疗

目的探讨氩氦靶向（氩氦刀）治疗颈淋巴结转移癌的可行性。方法15例颈淋巴结转移癌病灶在给予局部麻醉后进行氩氦靶向冷冻治疗,经历冷冻、升温两个循环。结果 14例患者的肿瘤病灶均被氢氦刀所形成的冰球完全覆盖,其余1例患者肿瘤病灶的冰球的覆盖率也在96％以上。在冷冻期间没有发生严重的并发症。结论氩氦靶向治疗能有效治疗颈淋巴结转移癌,创伤小,并发症低,是一种安全有效的肿瘤治疗方法。     

Current concepts in lip reconstruction

PURPOSE OF REVIEW: Approximately 25% of all oral cavity carcinomas involve the lips, and the primary management of these lesions is complete surgical resection. The management of the resulting lip defect remains a significant reconstructive challenge, requiring meticulous preoperative planning and surgical technique to optimize the functional and cosmetic outcome. Reviewed here are the accepted techniques of lip reconstruction, as well newer techniques that have been reported. RECENT FINDINGS: There have been no major advances in lip reconstruction; rather, continued improvement on accepted techniques. The main goals of reconstruction remain the restoration of oral competence, maintenance of oral opening, and the restoration of normal anatomic relations such that both the active (smile) and passive (form) cosmetic outcome is acceptable. The reconstruction should be tailored to the individual needs of the patient and should take into account the patient's condition, local tissue characteristics, previous treatment(s), and functional needs (eg, denture use), in addition to the size and location of the defect. SUMMARY: The lips play a key role in facial expression, speech, and eating. This requires meticulous attention to preoperative planning and surgical technique to maximize the functional and cosmetic outcome. It is important to assess local tissue characteristics (skin laxity) and previous treatment (surgery and/or irradiation) before the surgical plan is made final. Local tissue should be used whenever possible to provide the least donor site morbidity and the best overall tissue color and texture match. Whenever possible, dynamic reconstruction should be attempted. Careful preoperative assessment and planning will allow the surgeon to reach an acceptable balance between form and function with the reconstruction.