Review
Anaesthesia for endoscopic endonasal surgery

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Summary

Endoscopic endonasal surgeries are fast catching the imagination of both otorhinolaryngologist and neurosurgeons. Although traditionally done only for treatment of chronic rhino-sinusitis the approach is nowadays being utilised for varied pathological states on a wide anatomical expanse which is accessible via the endonasal corridor. The anatomical areas involved are not just paranasal sinuses but include the whole of the ventral base of skull, areas around the orbit and even upper cervical spine. The approach can be utilised for a myriad of pathology including resection of inflamed mucosa of the sinuses, correction of fractures of bones around nose, correction of cerebrospinal fluid rhinorhea and resection of benign and malignant tumours in paranasal sinuses and intracranially along the base of the skull. Thus it is evident that the perioperative anaesthetic management will have to be tailored according to the patient’s preoperative profile and the surgical needs. There, however, are some general concerns including provision of a blood less field, maintaining a good plane of anaesthesia and allowing a smooth recovery from anaesthesia which is common to all procedures. Techniques that can be utilised to provide for these and some special concerns in particular procedures are being discussed in this review.

Section snippets

Anaesthesia for endoscopic endonasal surgery

Endoscope based surgeries have become very popular in otorhinology practice. In the late 1980s removal of hypertrophic inflamed mucosa and debris following chronic sinusitis by endoscopy (known as functional endoscopic sinus surgery, FESS) was initiated. Thereafter endoscopic procedures have evolved tremendously and surgical correction for cerebrospinal fluid (CSF) rhinorhea,1 various skull base surgeries,2 resection of malignant and non-malignant tumours in and around the sinuses,3 reduction

Pre-anaesthetic check up and optimisation

It is important to review the medical management of these patients regarding intake of various hormonal preparations, steroids, non-steroidal anti inflammatory drugs (NSAIDS), bronchodilators and antibiotics. Other medications being taken by the patient for associated medical disorders should also be reviewed. Apart from this airway examination is important in such patients who are mouth breathers and/or have a history suggestive of obstructive sleep apnoea (OSA). It is also important to inform

Local anaesthesia and general anaesthesia

Many ENT surgeons advocate the use of loco regional anaesthesia with or without sedation for these procedures.7 Patients discomfort and pain may predict the impending intrusion into dangerous areas by the endoscope and prevent major complications. Endoscopic surgery under local anaesthesia (LA) may allow for a day care surgical procedure for the patient, however, extensive procedures, revision surgeries and uncooperative and paediatric age group patients will warrant use of general anaesthesia

Blood loss

Extent and pathology of the disease, vascularity of the lesion and the amount of blood loss expected should decide about the need for invasive monitoring required and the cannulation of large veins. Being an endoscopic procedure the main surgical requirement is a blood less field. Bleeding in the surgical field can lead to incomplete surgical procedure and increased risk of complications due to non visualisation of important structures. Many methods have been recommended in literature to

Recovery

A smooth recovery from anaesthesia is desirable in all surgical procedures but specially after endonasal endoscopic surgeries. Straining and coughing on the endotracheal tube may lead to increased bleeding from the operative site leading to collection of blood in the oropharynx which may either be aspirated or lead to complications like laryngospasm. Otolaryngological surgeries have an increased risk of development of postoperative laryngospasm. This has been attributed to increased secretions

Pain

Nasal endoscopic surgeries are thought to be associated with minimal or mild pain only. However Sommer et al. in a recent study to define the prevalence and predictors of postoperative pain in patients undergoing ENT surgery found that unacceptable high levels of pain were present in patients undergoing nasal endoscopic surgery.35 Almost 30% of these patients had a visual analogue score (VAS) of more than 40 mm on a scale of 0–100 at rest and nearly 40% had VAS more than 40 mm on coughing. Thus

Complications

The risk of serious complications after endoscopic sinus surgery has been reported to be less than 1% in the literature.37 The incidence and type of complication will also depend on the type of surgery being undertaken (Table 1). In general the complications include haemorrhage, intracranial, and ocular complications. Haemorrhage can commonly occur from the branches of sphenopalatine artery and less commonly from the anterior cerebral and internal carotid artery. Simple nasal packing is most of

Functional endoscopic sinus surgery

The term was coined by Kennedy et al. in the year 1985 in their classic paper on the theory behind the procedure.39 The procedure is based on the concept that minor pathological changes in the vicinity of the ostiomeatal complex may interfere with mucociliary clearance or with the ventilation of sinuses leading to inflammation and infection and the sinus mucosa will return to normal if adequate drainage can be re-established by removing the mucosal disease in this region.

The procedure is

Conflict of interest

None.

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