Unsedated Office-Based Laryngeal Surgery

TITLE: Unsedated Office-Based Laryngeal Surgery
SOURCE: Grand Rounds Presentation, UTMB, Dept. of Otolaryngology
DATE: April 16, 2008
RESIDENT PHYSICIAN: Murtaza Kharodawala, MD
FACULTY PHYSICIAN: Michael Underbrink, MD
SERIES EDITORS: Francis B. Quinn, Jr., MD

"This material was prepared by resident physicians in partial fulfillment of educational requirements established for the Postgraduate Training Program = of the UTMB Department of Otolaryngology/Head and Neck Surgery and was not intended for clinical use in its present form. It was prepared for the purp= ose of stimulating group discussion in a conference setting. No warranties, either express or implied, are made with respect to its accuracy, completen= ess, or timeliness. The material does not necessarily reflect the current or past opinions of members of the UTMB faculty and should not be used for purposes= of diagnosis or treatment without consulting appropriate literature sources and informed professional opinion."

Background

Laryngology has a un= ique and rich history that originates from the early 1800s when Bozzini developed the use of a mirror to perform indirect lary= ngoscopy for examination of laryngeal anatomy. In 1852, Green first described the use of direct laryngoscopy to perform a visually controlled endoscopic excision of laryngeal neoplasm. Cohen advanced the = field of laryngology by performing office-based mirror-guided surgery in his home in Philadelphia. With the use of cocaine to anesthe= tize mucosa, Koller and Jelinek= provided another integral step towards office-based laryngeal surgery. Chevalier Jackson in the 1900s pro= vided technical advances that are still in use today including perfecting direct = laryngoscopy in the supine position. Advancements in technology includi= ng the development of various types of rigid laryngoscopes, the use of an operating microscope, microlaryngeal instruments, optical telescopes, and CO2 laser have substantially increased the breadth of surgi= cal possibilities. Accordingly, t= he ability to provide appropriate anesthesia including jet ventilation, laser = endotracheal tubes, and other techniques have made su= rgical intervention for laryngeal disorders safer for patients. As we continue to broaden the scop= e of minimally invasive surgical interventions, office-based laryngeal surgery w= ill likely continue to grow and become popular not only for patients but for surgeons and likely reimbursement organizations.

Technologic Advanced for Office-Based Laryngeal Surg= ery

Among the advances that allow office-based laryn= geal surgery possible is the advent of the flexible fiberoptic endoscope in the 1970s. T= ransoral laryngeal procedures with specialized instruments also provide an ability to perform office-based surgery. Additionally, the integration of a distal chip camera in 1999 for tr= ansnasal esophagoscopy provided improved resolution, bri= lliant illumination, and the ability to pass instruments through a 2 mm working channel including the ability to suction or insufflate. Finally, most recently, the abilit= y to pass a fiber through this working channel to perform laser assisted surgery has allowed the ability to perform various procedures for = unsedated patients for certain disease processes.

Patient Selection

As with all surgical interventions, patient sele= ction is important for office-based laryngeal surgery. First and foremost, informed conse= nt is required with a thorough description of the risks and benefits involved in = the procedure from the use of anesthesia to the post-procedural care and management. Patients should be willing and cooperative in the office setting. Although a gag reflex is not neces= sarily a contraindication for an office-based procedure, it should be assessed pri= or to attempting it. For patient= s with an exquisitely hypersensitive gag reflex despite the use of anesthesia, an office-based procedure may not be successful. Patients should also be assessed f= or anxiety and pain tolerance to optimize the setting for procedures. At times, a mild oral sedative may= be taken 30 minutes to an hour prior to the procedure. Comorbid conditions such as cardiopulmonary disease, movement disorders, and the use= of anticoagulation therapy must also be assessed. Patients that may not pass operati= ve clearance may still be amenable to unsedated office-based surgery with appropriate level of monitoring. Patients with movement disorders m= ay require surgical intervention in the operating under general anesthesia as office-based procedures require a stationary patient. Finally, appropriate anatomy is re= quired to perform procedures. A pate= nt nasal airway and the ability to open the mouth at least 2 cm in interdental distance for transor= al instruments is necessary.

Anesthesia

The sensory innervation to larynx, trachea, and esophagus is from the vagus nerve. The internal branch of= the superior laryngeal nerve innervates the glottic= and supraglottic structures and the recurrent laryngeal n= erve innervates the subglottis. The trachea and esophagus are dire= ctly innervated from branches of the vagus nerve directly.

There are a variety of techniques that have been= used for anesthetizing the nose and upper aerodigestive tract. Although cocaine has b= een used extensively in the past, it has lost some popularity as adequate anesthesia may be achieved by other means.= In an article by Simpson et al. in 2004, the steps for topical anesthesia for the airway and esophagus were described. First, topical 2% oxymetazoline/tetracaine spray was administered into the nasal cavities. Then, topical benzocaine/tetracaine spray was applied to the palate and posterior pharynx. Finally, 3-5 cc of 4% lidocaine was dripped onto the tongue base and larynx= under fiberoptic guidance in several 0.5 – 1 cc aliquots. After about 10 – 15 minutes = of this topical anesthesia the procedure could be performed. Patients should also be informed to avoid oral intake of food or liquids for at least 45 – 60 minutes aft= er the procedure to avoid the risk of aspiration.

An alternative to this regimen is using nebulized form of 2% or 4% lidoc= aine, followed by the direct application of lidocaine= to the site of surgery though the flexible endoscope. Tessalon perles may also be used to topic= alize the pharynx. Additionally, lo= cal nerve block of the internal branch of the superior laryngeal nerve may be performed at the thyrohyoid membrane. There are various techniques avail= able, and choice of anesthesia may be by surgeon preference after appropriate experience.

When anesthesia is used, it is important to adhe= re to maximal dosing guidelines to avoid complications that may occur. For topical 4% lidocaine, 7 – 8 cc should be the limit used for an adult (4.5 mg/kg or about 30= 0 mg for a 70 kg patient). For 2% = tetracaine is used, a maximal amount that may be safe= ly used is 0.9 cc. For benzocaine/tetracaine spray a maximum of a 2 second s= pray may be used. When benzonatate perles are us= ed a maximal dose of 200 mg can be given to an adult patient.

Although adverse reactions to anesthesia are rar= e, it must always be acknowledged. A thorough history is important in determining any previous anesthesia-related complications for a patient. Systemic toxicities may include cardiovascular depression or arrest, convulsions, and respiratory arrest. Additionally, in patients that have renal, hepatic, and cardiac conditions these toxicities may be potentiated. <= /span>

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