4 - History, Physical Examination, and The Preoperative Evaluation

PART
II General Otolaryngology
4 History, Physical Examination,

and the Preoperative Evaluation
Ericka F. King
KEY POINTS the analysis of whether benefits outweigh potential harms. By

appropriately managing comorbidities perioperatively, risk can be
• A careful history and detailed physical examination are decreased to the utmost extent possible, and operative complications
the cornerstone of excellent patient care. can be reduced. Integral to this is an appreciation of the ideal set
forth in the Hippocratic Oath: “Above all else, do no harm.” It is
• The operating microscope and rigid and flexible the surgeon’s responsibility to ensure that appropriate patient
endoscopes are useful adjuncts to the basic head and assessment has been completed before entering the surgical suite.
neck examination. Establishing rapport with the patient
prior to their utilization, especially in vulnerable
patients, is critical to patient comfort, safety, and OBTAINING THE HISTORY
maximizing the information that can be obtained from The first step in gathering the patient history begins before the
the study. patient sets foot in the clinic, with a thorough review of patient
• Preoperative laboratory testing should be ordered based records to include:
on findings from the directed history and physical
• The referring physician’s concern that prompted the
examination, as well as the degree of anticipated surgical
patient’s visit
risk, and not on a routine basis.
• Relevant laboratory values and diagnostic studies, including
• Patients with active comorbid disease need a thorough previously obtained radiographic images and reports
preoperative evaluation. The otolaryngologist must work • Previous operative and pathology reports
closely with the patient’s primary care physician and • For malignant and unusual lesions, the original pathologic
appropriate subspecialists to ensure that a plan of action slides for review by the pathology department for a second
to mitigate associated increases in morbidity and opinion
mortality perioperatively is in place.
Electronic health records (EHRs) are increasingly used and
• Routine perioperative antibiotics can be eliminated in have the advantage of being more legible and less fragmented
most clean head and neck procedures that do not enter than paper records, and they are rapidly transferred electronically.
the aerodigestive tract, as well as straightforward However, a large amount of material is contained within the EHR,
clean-contaminated procedures, including much of which is not directly relevant to the visit, which necessitates
adenotonsillectomy and septoplasty. time to sift through. Variable formats among different software
• Bridging of patients on chronic oral anticoagulation packages present the consulting physician with additional challenges
therapy should be reserved for those at high risk for in efficiently identifying important information within EHRs.
perioperative thromboembolism, including those with The physician should first determine and document the patient’s
mechanical heart valves, active cancer, recent stroke, and chief complaint, which may differ from the referring physician’s
severe coagulopathy. objective for the consultation. Addressing the patient’s primary
concerns is important in establishing rapport, increasing the
efficiency and flow of the visit, and allowing the patient to par-
ticipate in his or her own care. The latter is one of the central
tenets of patient-centered care, an approach that may improve
The importance of obtaining a thorough history and physical both patient satisfaction and health outcomes.1,2
examination cannot be underestimated. In many cases, a care- The history of the present illness expands upon the chief
fully conducted clinical evaluation can elucidate the diagnosis. complaint. The physician must thoroughly understand the nature
In others, it is critical for directing further evaluation and for of the illness, including relevant temporal, aggravating, and relieving
avoiding unnecessary testing. Careful consideration of the patient’s factors, past therapy, and the presence or absence of pain. In the
presentation determines the urgency of further management and head and neck, many organ systems are intertwined, and it is
prevents potentially harmful delays in care. Otolaryngology–head critical to ask about the impact of the disease process on related
and neck surgeons are privileged in the extraordinary amount systems; for example, the presence of dysphagia in a patient with
of information that can be ascertained by a meticulous physical an airway complaint. As the practitioner listens to the patient, a
examination, because pertinent structures are easily accessed and picture emerges that includes a list of differential diagnoses to
extended evaluation tools, including fiberoptic endoscopes, are consider. Further questioning should be undertaken to begin to
readily available. discriminate between items on this list.
Likewise, the preoperative evaluation is a vital part of surgical A discussion of the patient’s medical history leads the otolar-
decision making. The patient’s comorbidities and other relevant yngologist to a better understanding of the patient and often
factors must be taken into account to accurately assess the risk reveals information that is important in the consideration of further
involved in a surgical procedure, and these must be weighed in workup and treatment. The practitioner should inquire about any
34
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CHAPTER 4 History, Physical Examination, and the Preoperative Evaluation 34.e1
Abstract Keywords
4
A careful history and physical examination is the cornerstone of history
excellent patient care. From review of records prior to the clinic physical examination
visit to extended examination with endoscopes, every step of the perioperative evaluation
complete history and head and neck examination is vital. Preopera- comorbid disease
tive evaluation and management of comorbid disease are also thromboembolism prophylaxis
critical. Preoperative investigations have utility in selected popula- anticoagulant bridging
tions, but routine usage should be avoided. Likewise, the use of
perioperative antibiotics and bridging of chronic anticoagulants
must be considered on an individual basis to avoid undue morbidity.
The otolaryngologist must be aware of diseases affecting other
organ systems that may impact the safety and success of their
surgery.
CHAPTER 4 History, Physical Examination, and the Preoperative Evaluation 35
previous emergency department visits, hospitalizations, and health TABLE 4.1 Karnofsky Performance Status Scale
problems that have required the care of a physician. A problem 4
Definition % Criteria
list of active health issues should be compiled and maintained,
reflecting any changes that occur while the patient is under the Able to carry on normal 100 Normal; no complaints; no
otolaryngologist’s care. A complete surgical history is important activity and to work; evidence of disease
to obtain to understand the impact of comorbidities on the current no special care is 90 Able to carry on normal activity;
complaint, to anticipate anatomic alternations, and to assess needed minor signs or symptoms of
disease
anesthetic risks that may be encountered, should further surgical
80 Normal activity with effort; some
treatment be undertaken. A history of difficult intubation is signs or symptoms of disease
particularly important to elicit to anticipate any challenges that Unable to work; able to 70 Cares for self; unable to carry on
may arise in the operating theater. live at home, care for normal activity or to do active
Medication allergies are crucial to note prominently in the most personal needs; work
medical chart. True allergy should be distinguished from adverse a varying amount of 60 Requires occasional assistance;
effects of a medication. In addition, all medications and current assistance is needed able to care for most personal
dosages should be accurately recorded, and compliance with needs
prescribed medications should be assessed. A history of noncompli- 50 Requires considerable assistance
and frequent medical care
ance may need to be taken into account when deciding between Unable to perform 40 Disabled; requires special care
courses of care, particularly when considering conservative manage- self-care; requires and assistance
ment that would require close observation and follow-up. equivalent of 30 Severely disabled; hospitalization
A careful social history must be obtained, including: institutional or is indicated, death not imminent
hospital care; disease 20 Very sick; hospitalization
• Tobacco exposure. Note first- and second-hand exposure, and may be progressing necessary; active supportive
specifically ask about cigarette, cigar, and chewing tobacco rapidly treatment necessary
consumption, either current or past use. 10 Moribund; fatal processes
• Alcohol consumption. Ask direct questions regarding the amount progressing rapidly
consumed, frequency, choice of beverage, and duration of use. 0 Dead
• Past and current recreational and intravenous (IV) drug use From Hanks G, Cherny NI, Christakis NA, et al. Oxford textbook of
• Sexual history. This is of particular importance in light of the palliative medicine, ed 4. New York, 2010, Oxford University Press.
role that human papillomavirus plays in some head and neck
cancers. Assessing risk for human immunodeficiency virus,
hepatitis C, and other sexually transmitted diseases is also
important.
practice of medicine and have the added benefit of showing the
• Other exposures. Occupational and vocational exposures to
patient that the examiner is concerned about disease transmission,
irritants, potential carcinogens, and noise should be elucidated
which builds trust.
if relevant to the chief complaint. A history of prior therapeutic
irradiation, including modality (implants, external beam, or by
mouth) and dosage should be ascertained. A history of accidental General Appearance
radiation exposure is also important to document.
Much information can be gleaned by assessing the general behavior
• Environment. An understanding of the patient’s physical living
and appearance of the patient. An assessment of the vital signs
environment and available social support is significant in
should be conducted. The level of alertness and orientation should
assessing postoperative needs and appropriate disposition
be noted, as well as the presence of signs of distress or toxicity,
planning. Assessment of the patient’s ability to perform critical
such as increased work of breathing, diaphoresis, and rigors. The
activities of daily living is equally important. One frequently
patient’s affect may suggest psychiatric issues such as depression,
utilized tool, especially in head and neck cancer patients, is the
anxiety, or frank psychosis. Acute intoxication may be evident and
Karnofsky Performance Status Scale (Table 4.1).3
may obviate the patient’s ability to consent to the examination or
The family history is often quite revealing, and asking patients treatment. Poor personal hygiene may be a clue to a difficult
questions about their familial history of hearing loss, congenital home environment or even homelessness, which the patient may
defects, atopy, or cancer may uncover pertinent information that have been reluctant to directly disclose when discussing social
may alter the direction of evaluation. history. Tar-stained fingernails, teeth, or moustache are harbingers
Finally, a review of systems is part of every comprehensive for heavy tobacco consumption. Disturbed gait and ability to
history. This review includes changes in the patient’s respira- navigate the examination room may point toward potential ves-
tory, cardiac, neurologic, endocrine, gastrointestinal, urogenital, tibular or neurologic impairment.
musculoskeletal, cutaneous, and psychiatric systems. A review of
all the elements of the complete history is given in Box 4.1.
Head and Facies
The head should be examined for overall shape, symmetry, and
PHYSICAL EXAMINATION signs of trauma. Areas of hair loss should be noted if relevant, and
The otolaryngologist must develop an approach to the head and scalp lesions should be identified. Facial skin is inspected for signs
neck examination that allows the patient to feel comfortable while of sun damage, lesions, and the presence of rhytids. The face is
the physician performs a complete and comprehensive evaluation. analyzed for the presence of dysmorphic features. Facial symmetry
Many of the techniques used by the otolaryngologist may leave is evaluated, both at rest and with motion. The American Academy
a patient feeling alienated if not done correctly. Thus it is essential of Otolaryngology–Head and Neck Surgery Facial Nerve Grading
to establish a rapport with a patient before proceeding with the System is a respected standard for reporting gradations of nerve
examination. function (Table 4.2).
The hands should be washed before and after each examination. The facial skeleton—including the bony nasal dorsum, orbital
Portions of the head and neck examination should only be done rims, malar eminences, maxilla, and mandible—should be carefully
with the examiner wearing gloves and, in some instances, protective palpated for bony deformities, irregularities, and step-offs; this is
eye covering. Universal precautions are mandatory in today’s especially important in patients with recent facial trauma. The
36 PART II General Otolaryngology
open and close the jaw. Dislocation, locking, or clicking of the

BOX 4.1 History joint is consistent with an intraarticular disk disorder, which can
be responsible for otalgia and headache.
Introduce yourself
The parotid gland should be inspected for overlying skin changes
REVIEW or gland enlargement and to identify visible masses. The glands
Medical records are then palpated to detect tenderness and characterize any masses,
Radiographic images including location, size, mobility, and compressibility. Bimanual
Laboratory values palpation with a gloved hand inside the oral cavity allows further
Pathology specimens evaluation of masses, as well as expressing saliva from Stenson’s
INQUIRE ABOUT CHIEF COMPLAINTS duct, important in suspected sialadenitis or sialolithiasis. The
preauricular and retroauricular lymph nodes should be systemati-
Location
cally assessed.
Duration
Temporal characteristics
Aggravating and relieving factors Eyes
Related complaints
The shape and angulation of the palpebral fissures are noted,
REVIEW PATIENT HISTORY along with any rounding of the canthi or increase in intercanthal
Medical history distance. The conjunctiva and sclera are inspected for any infection,
Surgical history swelling, or discoloration. The eyelids are assessed for retraction
Allergies and lid lag, which can be consistent with hyperthyroidism. The
Medications presence of strabismus or spontaneous nystagmus is noted, and
Social history extraocular movements are evaluated to provide an assessment of
Living situation the oculomotor, trochlear, and abducens nerves, and gaze-evoked
Family history nystagmus. The pupils are assessed for response to light and
RISK FACTORS accommodation. In some cases, fundal examination may be
important and can indicate the need for more detailed ophthal-
Tobacco and alcohol use
mologic examination.
Drug use
Sexual practices
REVIEW SYSTEMS Ears
Respiratory Auricles. The postauricular region should be inspected for healed
Cardiac surgical incisions. Clinical signs of mastoiditis that include tender-
Neurologic ness, erythema, and fluctuance should be sought in the patient
Endocrine with otalgia and fever. In trauma patients, ecchymosis overlying
Gastrointestinal the mastoid (Battle sign) is indicative of temporal bone fracture.
Urogenital The position and shape of the pinna should be noted, including
Musculoskeletal any asymmetry present. The overlying skin should be examined
Skin for evidence of erythema, drainage, and crusting consistent with
Psychiatric infection. Psoriasis of the auricle or external auditory canal with
its attendant flaking, dry skin, and edema is another common
finding. Ulcerations and rashes can be consistent with viral infec-
tions as a result of herpes simplex and herpes zoster. Signs of solar
TABLE 4.2 American Academy of Otolaryngology–Head and Neck damage and lesions consistent with skin cancer should be noted
Surgery Facial Nerve Grading System and warrant biopsy. Loss of the normal cartilaginous landmarks
Grade Facial Movement is seen in inflammatory and infectious lesions, as well as in the
setting of auricular hematoma. Pain upon manipulation of the
I Normal Normal facial function at all times
II Mild dysfunction Forehead: moderate to good function pinna indicates inflammation or infection of the pinna or external
Eye: complete closure auditory canal.
Mouth: slight asymmetry The areas anterior to the root of the helix and tragus may
III Moderate Forehead: slight to moderate have preauricular pits, sinuses, or skin tags. Any drainage should
dysfunction movement be noted.
Eye: complete closure with effort
Mouth: slightly weak with maximum External Auditory Canal. The outer third of the auditory canal
effort
is cartilaginous, with fairly thick skin that contains hair follicles,
IV Moderately severe Forehead: no movement
dysfunction Eye: incomplete closure
sebaceous glands, and apocrine glands that produce cerumen.
Mouth: asymmetric with maximum The inner two-thirds of the canal is osseous and has only a thin layer
effort of skin overlying the bone. To visualize the ear canal, gently grasp
V Severe dysfunction Forehead: no movement the pinna and elevate it superiorly and posteriorly to straighten the
Eye: incomplete closure canal and allow atraumatic insertion of the otoscopic speculum.
Mouth: slight movement The overall patency of the canal should be evaluated; difficulty in
VI Total paralysis No movement inserting a properly sized speculum could indicate the presence of
stenosis that may be congenital or acquired in nature.
Cerumen commonly accumulates in the canal, often obstructing
regions overlying the paranasal sinuses may be firmly palpated or it; this may require careful removal to ensure complete examination.
tapped for tenderness, which may be present during an episode The color and consistency of drainage or debris should be noted,
of sinusitis. The temporomandibular joint is evaluated by placing and cultures should be considered. Foreign bodies may be found,
the examiner’s fingers over the temporomandibular joint region with the majority lateral to the isthmus, and should be removed
anterior to the external auditory canal and asking the patient to with an operating microscope. Disk-style batteries need to be
removed emergently. Once the canal is clear of debris, the quality some ears. The clinician must also assess for areas of myringo-
of the ear canal skin should be evaluated. Erythema and edema sclerosis, which appear as chalky white patches, frequently seen 4
in the setting of white, moist debris is consistent with otitis externa. in regions of previous trauma. A thickened, erythematous membrane,
In older patients, atrophy of the external auditory canal skin is occasionally with bullae, is consistent with myringitis; but a thin,
frequently seen and may be associated with psoriasis or eczema atelectatic membrane draped closely over the underlying middle
of the canal. In addition, any masses or skin lesions should be ear structures may indicate adhesive otitis media, and prominent
noted. Cutaneous cancers, such as squamous cell carcinoma, can radial blood vessels can indicate a chronic middle ear effusion.
involve the ear canal skin, and careful documentation and biopsy Perforations should be noted with their location, proximity to the
of any lesions should be undertaken. The presence of granulation annulus, and approximate size expressed as a percentage of the
tissue at the junction of the cartilaginous and bony canal should drum perforated.
raise concern for malignant otitis externa, particularly in patients Pneumatic otoscopy should be performed, particularly when
who have diabetes or in those who are immunocompromised. middle ear disorders are of concern. First, an appropriately sized
Lacerations may be present in the setting of trauma, which may speculum is used to seal the ear canal. With gentle pressure from
include temporal bone fractures. the pneumatic bulb, the tympanic membrane will move back and
forth, if the middle ear space is well aerated. With a retracted
Tympanic Membrane. The tympanic membrane should be visible drum, it is helpful to depress the bulb prior to sealing the canal
after the canal has been cleared of any debris. As depicted in Fig. to generate negative pressure. Perforations and middle ear effusions
4.1, the membrane is oval and cone shaped, and it is surrounded are common causes of immobile tympanic membranes.
by the fibrous white annulus. The central portion of the membrane The middle ear should be assessed for the presence of any
attaches to the handle of the malleus, which terminates in the fluid. Serous effusions often appear as amber fluid, sometimes
umbo. The lateral process of the malleus is readily seen in the with air-fluid levels or air bubbles. Mucoid effusions will appear
superior tympanic membrane and will be quite prominent in dull gray to white in color, with loss of the typically visualized
retracted membranes. Superior to this process is the pars flaccida, middle ear landmarks, and the tympanic membrane will often be
wherein the tympanic membrane lacks the radial and circular retracted. White masses, often with associated perforation and
fibers present in the pars tensa, which comprises the remainder granulation tissue, are consistent with acquired cholesteatoma. A
of the eardrum. The pars flaccida must be critically examined, white pearl behind an intact tympanic membrane, often in the
because it is the most common location for retraction pockets, anterior-superior quadrant, is likely to represent congenital
debris, and cholesteatoma. The normal tympanic membrane should cholesteatoma. Vascular masses should prompt consideration of
be pearly gray and translucent, which allows examination of the middle ear glomus tumor; the clinician may also note a Brown
structures of the middle ear, including the promontory and round sign, in which the mass blanches with pneumatic otoscopy.
window. The stapes and eustachian tube opening are visible in
Hearing Assessment. Tuning fork tests, usually done with a
512-Hz fork, allow the otolaryngologist to distinguish between
sensorineural and conductive hearing loss (Table 4.3). Tuning fork
Pars tests have a role in assessing hearing when an audiogram is not
flaccida available, as well as in confirming audiometric findings. All tests
Posterior should be conducted in a quiet room without background noise
mallear fold and in ears cleared of cerumen and debris.
Lateral process The Weber test is performed by placing the vibrating 512-Hz
of malleus tuning fork in the center of the patient’s forehead, at the bridge
of the nose, or on the central incisors with the patient’s teeth
Malleus handle tightly clenched. The patient then is asked if the sound is louder
in one ear or is heard in the midline. The sound waves should be
POSTERIOR ANTERIOR
transmitted equally well to both cochleae through the skull. A
unilateral sensorineural hearing loss causes the sound to lateralize
to the ear with the better cochlear function. However, a unilateral
Umbo conductive hearing loss causes the Weber test to lateralize to the
side with the conductive loss, because less competing background
noise is detected through air conduction. A midline Weber result
is referred to as “negative.” “Weber right” and “Weber left” refer
Fig. 4.1 The tympanic membrane. to the direction to which the sound lateralized.
TABLE 4.3 Tuning Fork Testing

Weber Weber “Negative” Weber Right
Weber Sound is midline (“negative”): Sound localizes right or left:
normal ipsilateral conductive or contralateral sensorineural hearing loss
Rinne Air > bone conduction: Bone > air conduction:
normal or ipsilateral mild sensorineural hearing loss ipsilateral conductive hearing loss
Example:
1. Right conductive hearing loss: Weber lateralizes to right; Rinne on right bone > air
2. Right sensorineural loss: Weber lateralizes to left; Rinne air > bone bilaterally
Rinne Rinne “Positive” Rinne “Negative”
Patient response “Sound is louder when the fork is by the canal.” “Sound is louder when the fork is on the mastoid process.”
Interpretation Air conduction louder than bone conduction; normal Bone conduction louder than air conduction; conductive hearing loss
Begin with a 512-Hz fork; then include 256- and 1024-Hz forks.
TABLE 4.4 Tuning Fork Assessment of Degree of Hearing Loss and is not usually visible. In patients who have undergone endo-
scopic sinus surgery, many of the sinus ostia can be evaluated
Hearing Loss (dB) 256 Hz 512 Hz 1024 Hz
endoscopically. The procedure is then repeated on the other side.
<15 + + + Flexible fiberoptic scopes can also be used and are safer in young
15–30 – + + children and other unpredictable patients, but these often provide
30–45 – – + inferior optics and are less able to be directed into the lateral and
45–60 – – – superior aspects of the nasal cavity.
+: positive Rinne, air conduction > bone conduction.
−: negative Rinne, bone conduction > air conduction.
Nasopharynx
The nasopharynx extends from the skull base to the soft palate,
and this can be a challenging area to examine. In the patient
To further elucidate the nature of unilateral hearing loss, the with a high posterior soft palate and small tongue base, the oto-
Rinne test is performed. The 512-Hz tuning fork is placed firmly laryngologist may use a small dental mirror and a headlamp to
on the mastoid process, and patients are instructed to tell the visualize the nasopharynx. By having the patient sit upright in the
examiner when they are no longer able to hear the sound. The chair, the physician may firmly pull the tongue forward while
fork is then quickly transferred in front of the ear canal, and opening the patient’s mouth to place the mirror just posterior to
patients are asked if they can again hear sound. If the sound is the soft palate. The structures of the nasopharynx are seen when
still audible, it is deemed a positive test, indicating that air conduc- the mirror is oriented upward.
tion is greater than bone conduction; this is seen in ears with a Utilization of a fiberoptic nasopharyngoscope allows excellent
mild sensorineural loss, as well as normal hearing ears. If the visualization of this area. The midline also should be inspected
sound is no longer heard when the tuning fork is placed in front for any masses, ulcerations, or bleeding areas. Another technique
of the canal, bone conduction is deemed greater than air conduction, uses a 90-degree rigid scope, which is advanced through the mouth,
and this is termed a negative Rinne test consistent with conductive with the beveled edge placed posterior to the soft palate; the
hearing loss. These tests can be repeated with the 256- and 1024-Hz nasopharynx may be seen in its entirety, and both compared for
tuning forks; negative responses provide an indication of the degree symmetry using this technique.
of conductive hearing loss (Table 4.4). Regardless of the technique used, the adenoids, eustachian
tube orifice, torus tubarius, and fossae of Rosenmüller should
be inspected on each side. Whereas children have adenoid tissue
Nose present, adults should not have much adenoid tissue remaining in
The external nose should be inspected from the frontal, profile, this area; the presence of tissue should prompt consideration of
and base views for any deformity or asymmetry. The projection lymphoma or human immunodeficiency virus (HIV) infection. All
of the tip and dorsum and the width of the alar base are considered. patients with unilateral otitis media should have their nasopharynx
The soft tissue envelope is inspected for skin quality and thickness, inspected for possible nasopharyngeal masses. Nasopharyngeal
and for the presence of any lesions or discoloration. carcinoma most commonly presents in the fossa of Rosenmüller.
Anterior rhinoscopy using a headlamp and nasal speculum In young male patients, nasopharyngeal angiofibromas are locally
allows assessment of the nasal septum and inferior turbinates. aggressive but histologically benign masses that most commonly
The speculum should be directed laterally to avoid touching the occur in the posterior choana or nasopharynx. Cysts in the superior
sensitive septum with the metal edges. Drainage, clot, and foreign portion of the nasopharynx may represent a benign Tornwaldt
bodies should be noted. The anterior septum, where numerous cyst or a malignant craniopharyngioma.
small branches of the external and internal carotid arteries meet
(Kiesselbach plexus), should be evaluated for prominent, superficial
ectatic vessels that may be responsible for epistaxis. Anterior septal
Oral Cavity
deviations and bony spurs are often evident, and palpation of The boundaries of the oral cavity extend from the skin-vermillion
the anterior septum with gloved fingers can be helpful in deter- junction of the lips, hard palate, anterior two-thirds of the tongue,
mining the presence of caudal deviation. The characteristics of buccal membranes, upper and lower alveolar ridge, and retromolar
the mucosa of the inferior turbinate may range from the boggy, trigone to the floor of the mouth. The oral cavity may be best
edematous, pale mucosa seen in those with allergic rhinitis to visualized with a well-directed headlamp and a tongue depressor
the erythematous, edematous mucosa seen in those with sinusitis. in each gloved hand. A systematic approach to examination ensures
Polyps and masses may be visualized and warrant endoscopic that no mucosal surface will go unexamined.
examination. The patency of the nasal airway bilaterally should The lips and oral commissures should be carefully inspected
be noted. for any lesions concerning for carcinoma. Smooth submucosal
Nasal endoscopy using rigid endoscopes allows thorough nodules may denote a mucocele. Note any fissures or cracking
examination of even the most posterior portions of the nasal cavity consistent with angular stomatitis or cheilosis.
but carries a risk of laceration in an uncooperative patient. After Next, the patient is asked to open the mouth, and the presence
applying a local anesthetic and topical decongestant spray, the or absence of trismus is noted. The general condition of the teeth
rigid zero-degree endoscope may be passed into the nose along and gingiva should be noted along with the occlusion. The retro
the nasal floor, noting the appearance of the septum, inferior molar trigone should be inspected bilaterally; cancers in this area
turbinate, and eustachian tube orifice. The appearance of the are commonly asymptomatic until locally advanced, and the
mucosa following decongestion is noted, and it is compared with opportunity to identify small, asymptomatic lesions should not
the appearance on anterior rhinoscopy. The endoscope is then be missed.
removed and reintroduced above the inferior turbinate to view The dorsal, ventral, and lateral surfaces of the tongue should
the middle turbinate, and is again passed posteriorly to the be carefully inspected for induration or ulcerative lesions. Gently
nasopharynx. The tip is withdrawn to the head of the middle grasping the anterior tongue with a gauze sponge allows the
turbinate and is then directed laterally to view the lateral nasal examiner to move the anterior tongue from side to side, and asking
side wall, when the patient is able to tolerate this. Accessory ostia the patient to lift the tongue toward the hard palate allows examina-
from the maxillary sinus may be visible and often are mistaken tion of the floor of mouth and Wharton ducts. The examiner
for the true maxillary ostium, which is located behind the uncinate should palpate the floor of the mouth using a bimanual approach.
The buccal mucosa should be inspected for white plaques that these may be removed with a cotton-tipped swab. Tonsillar asym-
may represent oral thrush, which easily scrapes off with a tongue metry is most often benign, but when the enlarged tonsil has an 4
blade, or leukoplakia, which cannot be removed. More worrisome atypical appearance, lymphoma must be considered.
for a precancerous condition is erythroplakia. Therefore, all red The tonsillar pillars, soft palate, uvula, and lateral and posterior
lesions and most white lesions should be biopsied. While examining pharyngeal walls are then inspected. Bulges in the soft palate or
the buccal membranes, the physician should note the location of pharyngeal walls can indicate an abscess, mass, or aneurysm; palpa-
the parotid duct, or Stenson duct, as it opens near the second tion of these areas can be very helpful but may trigger the patient’s
upper molar. Small yellow spots in the buccal mucosa are sebaceous gag reflex. Deviation of the uvula is seen with masses of the lateral
glands, commonly referred to as Fordyce spots, and are not abnormal. soft palate, most commonly peritonsillar abscesses. Elongation of
Aphthous ulcers, or the common canker sore, are painful white the uvula may be seen in sleep apnea. A bifid uvula may occur in
ulcers that can be on any part of the mucosa but are commonly isolation, or it can be accompanied by midline lucency of the soft
present on the buccal membrane. palate and a notch on the posterior hard palate, which is consistent
The hard palate may have a bony outgrowth known as a torus with a submucosal cleft palate. Cobblestoning of the mucosa in
palatinus. These midline bony deformities are benign and should the posterior oropharynx indicates the presence of submucosal
not be biopsied, although growths that are not in the midline lymphoid hypertrophy and is often seen in the setting of infection,
should be more carefully evaluated as possible cancerous lesions. allergic rhinitis, and reflux.
Similar bony lesions along the lingual surface of the mandible, The base of the tongue can be visually inspected with the aid
called mandibular tori, may also be present. of a dental mirror and can be palpated with a gloved finger. The
patient should be aware of the possibility that gagging may ensue
when this is done. In patients with strong gag reflexes, with anatomy
Oropharynx unfavorable for mirror examination, or when a concerning lesion
The oropharynx includes the posterior third of the tongue, the needs to be thoroughly examined, flexible fiberoptic examination
anterior and posterior tonsillar pillars, the soft palate, the lateral may be necessary. By carefully passing the flexible fiberoptic
and posterior pharyngeal wall, and the vallecula (Fig. 4.2). endoscope through the anesthetized nose, the interaction of the
The tonsil size is typically denoted on a scale, and many scales soft palate and tongue base during swallowing also may be viewed.
are in use. The Brodsky scale appears to have reasonable intra
observer and interobserver reliability.4 With this scale, 0 indicates
the tonsils are entirely within the tonsillar fossa; 1+ indicates the
Larynx and Hypopharynx
tonsils are located just outside the fossa and occupy less than 25% The larynx is often subdivided into the supraglottis, glottis, and
of the total width of the oropharynx; 2+ tonsils occupy 26% to subglottis. The area of the supraglottis includes the epiglottis, the
50%; 3+ tonsils are 51% to 75% of the oropharyngeal width; and aryepiglottic folds, the false vocal cords, and the ventricles. The
4+ tonsils occupy more than 75% of the oropharyngeal width. glottis comprises the inferior floor of the ventricle, the true vocal
The term “kissing tonsils” implies that the tonsils meet in the folds, and the arytenoids. The subglottis generally is considered to
midline, entirely within the tonsillar fossa. The surfaces of the begin 5 to 10 mm below the free edge of the true vocal fold and
tonsils are examined for concerning lesions, exudates, erythema, to extend to the inferior margin of the cricoid cartilage (Fig. 4.3).
and tonsilliths. A common cause for a foreign body sensation in The hypopharynx extends from the superior edge of the hyoid
the back of the throat, tonsilliths are yellow or white concretions bone to the inferior aspect of the cricoid cartilage and is composed
in the tonsillar crypts which often cause the patient to have halitosis; of three subsites: (1) the piriform sinuses, (2) the posterior hypo-
pharyngeal wall, and (3) the postcricoid area. This area, rich in
lymphatics, may harbor tumors that often are detected only in
advanced stages; early detection of these relatively “silent” carci-
nomas is important and should not be missed.
The examiner should not only detect anatomic abnormalities
but also should observe how the larynx and hypopharynx are
Supraglottis
Hyoid bone
ANTERIOR POSTERIOR
Glottis
Thyroid cartilage
Subglottis
Fig. 4.2 The oropharynx, which includes the posterior third of the
tongue, soft palate, tonsillar pillars (anterior and posterior), lateral and
posterior pharyngeal wall, and vallecula. Fig. 4.3 The larynx.
functioning to allow the patient to have adequate airway, vocaliza- laryngoscopy. True vocal fold motion also needs to be assessed,
tion, and swallowing. and some maneuvers allow better visualization of the larynx and
Correct positioning is critical to the successful performance its related structures. Panting, quiet breathing, and phonating
of indirect laryngoscopy. The patient’s legs should be uncrossed with a high-pitched “eeee” aids in assessing true vocal fold function.
and placed firmly on the footrest. The back should be straight True vocal fold paralysis and subtle gaps present between the folds
with the hips planted firmly against the chair. While leaning slightly during cord adduction should be noted.
forward from the waist, the patient should place the chin slightly During abduction of the cords, the subglottic area may occasion-
upward in a sniffing position. The patient’s tongue is pulled forward ally be viewed. A prominent cricoid cartilage, seen inferiorly to
by the examiner, who grasps the tongue with a gauze sponge. The the anterior commissure, may be mistaken for a subglottic stenosis.
examiner’s middle finger is extended to retract the patient’s upper It is difficult to fully inspect the subglottic area in the office setting.
lip superiorly, and a dental mirror is warmed to prevent fogging Any concerns about subglottic inflammatory swelling, masses, or
and is placed in the oropharynx to elevate the uvula and soft palate stenosis should be addressed in an operative setting or through
to view the larynx (Fig. 4.4). The patient with a strong gag reflex radiographic imaging.
may benefit from a small spray of local anesthetic. Rigid telescopic The piriform sinuses are often collapsed at rest. When the
examination is performed in a similar manner with a variety of hypopharynx is examined endoscopically, patients should be asked
angled telescopes and permits photodocumentation. Alternatively, to close their mouth and puff out their cheeks; this expands the
examination with a flexible fiberoptic scope allows excellent area and permits mucosal inspection. Pooling of saliva should be
visualization and improved ability to phonate and swallow during noted and can indicate dysphagia as a result of lack of pharyngeal
the examination, because the tongue is not tethered anteriorly; sensation or esophageal obstruction. The postcricoid area has a
this is usually very well tolerated. rich venous plexus that can be quite prominent, which leads to a
The epiglottis should be crisp and without lesions. An submucosal bulge or purple discoloration of the mucosa; this can
erythematous, edematous epiglottis may signify epiglottitis, a serious be confused with a vascular neoplasm.
infection that mandates consideration of airway control. The petiole
of the epiglottis is a peaked structure on the laryngeal surface of
the epiglottis above the anterior commissure of the true vocal
Neck
folds. It may be confused with a cyst or mass, but it is a normal The neck, an integral part of the complete otolaryngology examina-
prominence. Irregular mucosal lesions may be carcinomas and tion, is best approached by palpating it while visualizing the
require further evaluation. underlying structures (Fig. 4.5). The midline structures, such as
In the posterior glottis, movement of the arytenoids allows the trachea and larynx, are usually easily located and palpated. In
determination of true vocal fold mobility. The interarytenoid thick, short necks, the “signet ring” cricoid cartilage is a good
mucosa may be edematous or erythematous and sometimes landmark to use for orientation. In young children, the laryngeal
represents gastroesophageal reflux laryngitis. The mucosa over and tracheal cartilages are very soft and compliant, and it can be
the arytenoids may be erythematous as a result of rheumatoid difficult to accurately ascertain landmarks by palpation. The hyoid
arthritis or as a result of recent intubation trauma. The posterior bone is often the most prominent structure in the anterior neck
glottis should be examined for the presence of webs or scars.
The true vocal folds should have translucent white, crisp borders
that meet each other on phonation. Edema of the folds that extends
for the entire fold length is often caused by Reinke edema, fre-
quently seen in tobacco abusers. Ulcerative or exophytic lesions
deserve further investigation and usually require operative direct
Submandibular
glands
Hyoid bone
Thyroid cartilage
Cricoid cartilage
Fig. 4.5 Basic anatomy of the anterior neck. Visualize structures

Fig. 4.4 The indirect laryngeal mirror examination. while performing neck examination.
ANTERIOR
POSTERIOR
TRIANGLE
TRIANGLE
Submandibular
triangle P
Carotid triangle IA
Occipital
Muscular IB R
triangle IIB S
IIA
Supraclavicular
VI
III
Fig. 4.6 Triangles of the neck. The anterior triangle is divided from VA
the posterior triangle by the sternocleidomastoid muscle.
IV VB
Fig. 4.7 Lymph node regions of the neck.

in children, and it can overlie the thyroid cartilage. In adults, a
palpable “click” should be evident when the larynx is moved back
and forth in a lateral direction. Any deviation of the airway should
be noted. Subcutaneous crepitus can indicate laryngeal fracture, to the superior border of the clavicle. For levels III and IV, the
and it can also be seen in the setting of air migrating upward from anterior boundary is the lateral border of the sternohyoid muscle,
a fresh tracheotomy site, esophageal rupture, or primary pneu- and the posterior limit is the lateral border of the sternocleido-
momediastinum. In the stridulous patient, auscultation of the mastoid muscle.
airway at various levels can help localize the region of restricted Level V encompasses the posterior triangle, which includes the
airflow. Neck range of motion should also be assessed. spinal accessory and supraclavicular nodes, and it encompasses
the nodes from the lateral border of the sternocleidomastoid muscle
Triangles of the Neck. Most physicians find it helpful to define to the anterior border of the trapezius muscle. Sublevel VA (spinal
the neck in terms of triangles when communicating the location accessory nodes) is separated from sublevel VB (transverse cervical
of physical findings (Fig. 4.6). The sternocleidomastoid muscle and supraclavicular nodes) by a plane that extends from the inferior
divides the neck into a posterior triangle—whose boundaries are border of the cricoid cartilage. Of note, the Virchow node is not
the trapezius, clavicle, and sternocleidomastoid muscles—and an in the VB region but is located in level IV.
anterior triangle bordered by the sternohyoid, digastric, and The pretracheal, paratracheal, precricoid (delphian), and
sternocleidomastoid muscles. These triangles are further divided perithyroid nodes are contained in level VI, which extends from
into smaller triangles: the posterior triangle comprises the supra- the hyoid bone to the suprasternal region. The lateral borders
clavicular and the occipital triangles; the anterior triangle may be are the common carotid arteries.
divided into the submandibular, carotid, and muscular triangles. Although not part of this classification system, the parotid/
preauricular, retroauricular, and suboccipital regions are commonly
designated the P, R, and S regions, respectively.
Lymph Node Regions
Another classification system for neck masses, endorsed by the Adenopathy and Masses. Systematic palpation of all neck levels
American Head and Neck Society and the American Academy of allows detection of masses and enlarged lymph nodes. Palpable
Otolaryngology–Head and Neck Surgery, uses radiographic nodes should always be noted and may need evaluation with either
landmarks to define six levels to depict the location of adenopathy fine-needle aspiration or radiologic imaging, if the clinical course
(Fig. 4.7): level I is defined by the body of the mandible, the or examination is concerning for an infectious or malignant process.
anterior belly of the contralateral digastric muscle, and the sty- In adults, nodes greater than 1 cm in size are more likely to be
lohyoid muscle; level IA contains the submental nodes; and level pathologic; in children, nodes greater than 1.5 cm in greatest
IB consists of the submandibular nodes. Levels IA and IB are diameter are concerning. In the superior cervical chain, it is very
separated by the ipsilateral anterior belly of the digastric muscle. common to have multiple, borderline, enlarged, indistinct, or
The upper third of the jugulodigastric chain is known as level slightly firm nodes that are often termed “shoddy.” In the sub-
II, whereas the middle and lower thirds represent levels III and mandibular area, it often is difficult to distinguish masses from
IV, respectively. More specifically, the jugulodigastric lymph nodes the normal architecture of the submandibular gland; bimanual
from the skull base to the inferior border of the hyoid bone are palpation of this area using a gloved finger in the floor of the
located in level II. In addition, sublevel IIA nodes are located medial mouth is helpful. The mobility of the mass in relation to the
to the plane defined by the spinal accessory nerve, and sublevel overlying skin and surrounding structures is important to note.
IIB nodes are lateral to the nerve. The carotid artery, often mistaken for a prominent node, can be
Level III extends from the inferior border of the hyoid bone differentiated by its prominent pulsation. The carotid and other
to the inferior border of the cricoid cartilage, and level IV includes seemingly vascular masses can be auscultated for the presence
the lymph nodes located from the inferior border of the cricoid of bruits.
neurologic examination that is beyond the scope of this chapter,

Thyroid Gland although much valuable clinical information can be obtained with
The thyroid gland resides below the cricoid cartilage and overlies an evaluation of the cranial nerves.
the anterior trachea. It is best examined by standing behind the
patient and placing both hands on the paratracheal area near the
cricoid cartilage. Having the patient swallow or drink a sip of
SPECIAL POPULATIONS
water often helps better delineate the thyroid lobes by having the
trachea rise and fall. Pressing firmly in one tracheal groove allows
Trauma Patients
the contents of the other side to be more easily distinguished by Patients seen in the setting of acute trauma warrant an expedited
gentle palpation. Diffuse tenderness and fullness of the gland is approach. Assessment of the stability and patency of the airway
recognized. Nodules or cystic structures should be carefully noted is of utmost concern, and otolaryngologists are the best-qualified
and evaluated, often by fine-needle aspiration. Adjacent adenopathy personnel to provide such an assessment. When acute, life-
in level VI also should be carefully assessed. threatening compromise is present, a safe airway must be established
by the most appropriate nonsurgical or surgical technique with
attention to cervical spine immobilization, a thorough discussion
Skin of which is beyond the scope of this chapter. Attention must then
While progressing through the detailed head and neck examination, be paid to establishing adequate respiration and addressing any
the skin covering the face and neck is carefully assessed. The cardiovascular compromise. Following that, a focused history is
external auricles often receive sun exposure and are at risk for taken. The mechanism of trauma is important to elucidate, as well
developing skin malignancies such as basal cell carcinoma and as whether any loss of consciousness occurred. Major medical
squamous cell carcinoma. The scalp should also be examined for comorbidities and a list of current medications should be obtained
hidden skin lesions such as melanoma, basal cell carcinoma, and when possible. Directed physical examination is then undertaken
squamous cell carcinoma. All moles should be inspected for irregular to identify any major comorbidities in addition to any injuries to
borders, heterogeneous color, ulcerations, and satellite lesions. In neural, vascular, and aerodigestive structures. The thorough history
patients with hemangiomas and vascular birthmarks of the head and physical examination detailed in this chapter should be
and neck, any birthmarks elsewhere on the body should be assessed. undertaken once the patient is stable and acute injuries have been
addressed.
Neurologic Examination
Table 4.5 outlines the basics of a neurologic examination appropriate
Children
for most head and neck patients. Patients who come to medical Infants and young children are not able to give a detailed
attention with vertigo or disequilibrium require a highly specialized subjective history. Information must be gleaned from their
caregiver’s observations, which may lack objectivity because of
the deep level of concern most people have for their children.
Practitioners frequently need to rely more heavily on their own
TABLE 4.5 Neurologic Examination
objective evaluation. At the same time, patient fear and lack of
cooperation can significantly limit the ability to perform a careful
CNs Tests examination, which presents a challenge in ascertaining a clear
I Formal or informal smell identification test (such as UPSIT) picture of the patient’s problem and likely diagnosis. A high index
Do not use ammonia (common chemical sense caused by of suspicion for congenital anomalies and syndromes must be
CN V stimulation) maintained.
II Visual acuity and visual fields
Pupillary reaction to light (afferent limb)
Inspect optic fundi Older Patients
III, IV, VI Extraocular movements in six fields of gaze
Pupillary reaction to light (CN III, efferent limb)
Of all surgeries currently performed, 25% to 33% are performed
Inspect for eyelid ptosis (CN III; also sympathetic nerves) on people older than 65 years of age; this percentage is likely to
V Palpate temporal and masseter muscles for contraction with increase as the population ages. A greater likelihood of comorbid
clenching jaw conditions exists with increasing age. In addition, physiologic
Test forehead, cheeks, jaw for pain, temperature, and light reserve is often compromised. Preoperative assessment in this
touch population should take these considerations into account and must
Corneal reflex (blinking in response to cotton touching the weigh the benefit of the procedure against the oft increased risks
cornea) in this population. Consultation with the anesthesia service
VII Symmetry of face in repose
facilitates planning for high-risk older patients.
Raise eyebrows, frown, close eyes tightly, smile, puff out
cheeks Approximately 50% of all postoperative deaths in older adults
VIII Auditory—tuning fork tests for hearing occur secondary to cardiovascular events. Severe cardiac disease
Vestibular—nystagmus on lateral gaze; Hallpike-Dix test; should be treated before any elective procedure and should be
head shaking; caloric testing; Frenzel lenses weighed against the benefit of any more urgent procedure. If
IX, X Listen for vocal hoarseness surgery is required, cardiac precautions should be instituted. Patients
Assess true vocal cord mobility with laryngeal mirror, with physical evidence or a history of peripheral vascular disease
fiberoptic scope should be evaluated for carotid artery stenosis. If a critical stenosis
Gag reflex
is identified, carotid endarterectomy should be performed before
Movement of soft palate and pharynx on phonation
XI Shrug shoulders against examiner’s hand (trapezius muscle)
any elective procedure that requires a general anesthetic. The
Turn head against examiner’s hand (sternocleidomastoid risk of a cerebrovascular accident should be considered when
muscle) evaluating patients for more urgent procedures. From a respiratory
XII Stick tongue out, assess for deviation (toward side of lesion) standpoint, increasing age leads to loss of lung compliance, stiffening
Tongue atrophy, fasciculations of the chest wall, and atrophy of respiratory muscles. In many
CN, Cranial nerve.
otolaryngology procedures, the surgeon should consider the risk
of intraoperative or postoperative aspiration and postobstructive
pulmonary edema. Patients with borderline pulmonary func- by patients do not represent true allergic phenomena but are
tion may not tolerate even mild respiratory complications. The simply drug side effects. Nonetheless, these reactions require 4
function of all the organ systems diminishes with age, neces- thorough documentation and avoidance of the allergens in the
sitating a thorough preoperative evaluation to maximize older perioperative period.
patient safety. Anaphylaxis results in the release of potent inflammatory
agents, vasoactive substances, and proteases, all of which bring
about the shock reaction. Urticaria, profound hypotension,
PREOPERATIVE EVALUATION tachycardia, bronchoconstriction, and airway-compromising
The patient who requires surgical management must be carefully edema of the mucosal surfaces of the upper aerodigestive tract
evaluated to identify medical comorbidities that may require may develop. Even in intubated patients, rapid oxygen desaturation
additional testing, prophylactic measures, and behavioral modifica- is often a prominent feature. As the reaction progresses, cardiac
tion before surgery in order to maximize the surgical outcome. arrest can ensue despite maximal resuscitative efforts. Given
In addition, the patient’s prior anesthetic record provides invaluable the potential morbidity and mortality of anaphylactic reactions,
insight into issues such as airway management and overall tolerance the otolaryngologist must identify all of a patient’s allergens in the
of general, regional, local, or neuroleptic anesthesia. A complete preoperative phase.
list of current medications and allergies must be obtained. The Antibiotics in the penicillin family are frequently given
social history can provide a means of anticipating postoperative in the perioperative period. The incidence of serious adverse
needs and circumventing some prolonged admissions. Any sig- reactions to penicillin is about 1%. It is widely believed that
nificant issues should be raised with the departmental or hospital there is a 10% to 15% chance that patients who manifest these
social worker, preferably before surgery. reactions also react adversely to cephalosporins. The notion of
Further preoperative testing should be based on findings from cross-reactivity with penicillin on skin testing seems to stem
the preoperative history and physical examination as well as the from data obtained in the 1970s, in which contamination of
degree of risk associated with the surgery, rather than as a matter cephalosporins with penicillin was subsequently proven. Unless
of course.5 Baseline laboratory studies, including a complete blood the patient has a history of significant atopy or penicillin-induced
count (CBC), metabolic panel and coagulation studies are not urticaria, mucosal edema, or anaphylaxis, cephalosporins can be
necessary in healthy individuals without significant comorbid given with little risk. Cephalosporins do cause hypersensitivity
disease, when surgery is expected to result in minimal blood loss. reactions independently, however, and adverse reactions to this
Screening electrocardiograms (ECGs) are frequently performed; family of medications should be noted. If a serious penicillin
however, there is little evidence that ECGs provide useful prognostic allergy is evident, alternative antibiotics, such as clindamycin, may
data in lower-risk surgeries. Patients with known cardiovascular be substituted.
disease or who are undergoing higher-risk surgeries are more Mucosal absorption of latex protein allergens from the surgeon’s
likely to benefit from ECG. The role of age is controversial. Some gloves can rapidly incite anaphylactic shock in patients who are
studies have found that 25% of individuals will have abnormal highly sensitive to latex. About 7% to 10% of health care workers
ECGs by the age of 60, but there is no clear consensus on an age regularly exposed to latex and 28% to 67% of children with spina
at which preoperative ECG is mandatory. Likewise, in patients bifida demonstrate positive skin tests to latex proteins.6 Preopera-
with stable, asymptomatic cardiac disease, preoperative evaluation tively, if a patient gives a history suspicious for latex allergy, precau-
with an echocardiogram and/or stress test is not needed in patients tions to avoid latex exposure must be instituted, and alternative
that are undergoing low- to moderate-risk noncardiac surgery. materials must be used in the operating suite.
Women of childbearing age should undergo pregnancy testing Similarly, patients with allergic or adverse reactions to soybeans
prior to surgery. or eggs may react to propofol, a ubiquitous induction agent.
When the need arises, consultation with appropriate specialties Protamine and IV contrast agents can potentially provoke hyper-
should be sought quickly. The consultant should be clearly informed sensitivity responses in patients with known shellfish or other fish
about the nature of the proposed procedure and should be asked allergies. Although rare, some patients have allergic reactions to
to comment specifically on the relative safety of performing the ester types of local anesthetics such as cocaine, procaine, and
procedure with respect to concomitant disease processes. In cases tetracaine.
complicated by many medical problems, or when the establishment If the suspicion of allergy or adverse reaction exists, the best
of a safe airway is an issue, close consultation with the anesthesia course of action is to avoid use of the potential offending agent
team is advised to avoid undue delay, cancellation of the procedure, altogether during surgery. If this is not feasible for some reason,
or an undesirable outcome. the surgeon and anesthesiologist should plan on premedicating
the patient with systemic steroids, histamine antagonists, and even
bronchodilators. The physician should then be prepared to deal
Informed Consent with the potential worst-case scenario of anaphylactic shock.
Although a detailed discussion of the legal ramifications of informed
consent is beyond the scope of this chapter, the ethical ideal deserves
consideration. An integral part of the preoperative process is the
Routine Perioperative Antibiotics
physician’s thorough and candid explanation to the patient of the Currently, evidence does not support routine perioperative antibiot-
procedure, its risks, and the probable outcomes. The relationship ics for many otolaryngologic procedures.7 In otherwise healthy
that develops between the surgeon and patient at this time often patients, prophylactic antibiotics should be given in complex
does more to prevent litigation if an unfortunate circumstance clean-contaminated surgeries, including revision septorhinoplasty,
occurs than any legal document detailing the risks and benefits. anterior skull base, and head and neck procedures with entry into
The potential risks and outcomes that would sway a patient’s the aerodigestive tract. Prophylaxis can be considered in additional
decision to undergo the procedure must be discussed with the cases, including cochlear implantation, surgery on a draining ear,
patient and documented in the chart. and neck dissections. For all other cases, including routine
endoscopic sinus surgery, clean head and neck cases, thyroidectomy,
and adenotonsillectomy, no routine antibiotic should be given.
Allergy Prophylaxis should not be continued beyond 24 hours after surgery,
The surgeon must guard against anaphylactic reactions in all except in the event of nasal packing, microvascular free flap, or
patients. In most instances, many of the drug reactions described skull base surgery.
In a patient who has undergone percutaneous coronary interven-

Chronic Anticoagulation tion, noncardiac surgery should be delayed for at least 1 month
Chronic oral anticoagulant therapy is often used to treat atrial after placement of a bare-metal stent. If a drug-eluting stent is
fibrillation, mechanical heart valves and left ventricular assist placed, surgery should ideally be delayed for 6 months. Patients
devices, and thromboembolism. Interrupting therapy for surgery with a history of stent placement for myocardial infarction have
has been thought to place some patients at increased risk for a greater perioperative mortality risk; if possible, surgery should
thromboembolism, and preoperatively the decision must be made be delayed for 6 months regardless of stent type.9
regarding whether or not to bridge with a short-acting anti Perioperative beta blockade has been used perioperatively to
coagulant. Bridging is associated with a higher risk of major and decrease cardiac complications. For noncardiac surgery, a recent
minor bleeding, which is not offset by a lower rate of deep vein Cochrane systematic review of 35 trails found that β-blockers
thrombosis, pulmonary embolism, or death in many patients8; reduced the occurrence of acute myocardial infarction and
thus the risk of both surgical bleeding and the patient’s risk for myocardial ischemia, arrhythmias, and congestive heart failure,
thromboembolism must be carefully weighed. The CHADS2 score but were associated with an increase in rate of stroke and all-cause
can be calculated to estimate risk of stroke in atrial fibrillation; mortality.10 However, the quality of evidence was low to moderate
one point is given for each factor including congestive heart failure for most trials, and the authors concluded that more evidence was
(ejection fraction ≤35), hypertension, age ≥75 years, and diabetes needed for a definitive recommendation to be made. Perioperative
mellitus, with two points given for history of stroke, transient statins have also been investigated, with mixed results in improve-
ischemic attack, or systemic emboli. ment of mortality.9 Patients who meet clinical criteria for statin
Currently, the American Academy of Cardiology recommends use do show clear benefits with perioperative use.
continuing therapeutic oral anticoagulants throughout the peri- Patients are typically maintained on their antihypertensive,
operative period for cases in which the risk of bleeding is low, antianginal, and antiarrhythmic regimens up to the time of surgery.
including endoscopy and biopsies.8 For other procedures, inter- Certain medications, such as diuretics and digoxin, may be withheld
ruption of oral anticoagulation may be necessary. Patients at low at the discretion of the anesthesiologist or cardiologist. Preopera-
to moderate risk for thromboembolism may be managed without tively, serum electrolytes and antiarrhythmic levels should be
bridging. Those at high risk, such as patients with active cancer, checked and adjusted as necessary. Coagulation studies (prothrombin
mechanical valvular prosthesis, recent stroke or transient ischemic time [PT]/partial thromboplastin time [PTT]) and platelet
attack, atrial fibrillation with CHADS2 score of 5 or 6, venous quantification are routinely obtained in patients with cardiovascular
thromboembolism in preceding 3 months, or severe clotting risk factors, because significant bleeding can lead to major peri-
disorder should be managed with bridging. A conservative approach operative cardiovascular complications. A relatively current chest
to bridging is currently advocated, including low-dose heparin radiograph is considered essential in this high-risk group.
pre- and postoperatively, or only postprocedurally. Nonpharma- Antibiotic prophylaxis should be planned in patients with
cologic approaches, including early ambulation and sequential prosthetic valves, a history of endocarditis, unrepaired congenital
compression devices, should be utilized. heart defects, cardiac transplant recipients with valvulopathy, or
in hypertrophic cardiomyopathy. According to the American Heart
Association, one dose of ampicillin given 30 to 60 minutes before
CONSIDERATIONS BY ORGAN SYSTEM incision is adequate prophylaxis for respiratory tract procedures.
The dosage is 2 g in adults and 50 mg/kg (up to 2 g) in children.
Cardiovascular In penicillin-allergic patients, cefazolin, ceftriaxone, or clindamycin
Cardiovascular complications are the most common cause of may be used.11 Patients with pacemakers or implanted defibrillators
perioperative mortality; perioperative myocardial infarction is and those with mitral valve prolapse do not require endocarditis
associated with an almost 50% mortality rate. Emergency surgery prophylaxis.
poses an additional risk for cardiovascular complications. Meticulous Airway, carotid, and vagus nerve manipulation can induce
review of the cardiovascular system is of utmost importance in bradycardia and hypotension. Agents such as lidocaine, epinephrine,
determining a patient’s surgical candidacy, especially in those who and cocaine, which are frequently used in sinonasal surgery, can
will require a general anesthetic. trigger undesirable cardiovascular events. Injury to the cervical
The otolaryngologist should look for: sympathetic chain may precipitate postural hypotension post-
operatively. Finally, the surgeon must also be cognizant that a
• A history of structural heart disease, arrhythmias, myocardial
unipolar electrocautery device can reprogram a pacemaker during
infarction, angina, history of angioplasty or bypass surgery,
surgery.
congestive heart failure, as well as peripheral vascular disease,
stroke, transient ischemic attacks, and hypertension
• Tobacco and alcohol abuse Respiratory
• Symptoms of exercise intolerance, dyspnea on exertion, par-
Postoperative pulmonary complications are the second most
oxysmal nocturnal dyspnea, claudication, syncope, palpitations,
common cause of perioperative mortality. Atelectasis and ventilation/
and chest pain
perfusion mismatch occur secondary to a number of factors in
• Examination findings including nonsinus rhythm, third heart
the operative setting, including the use of anesthetic agents, positive
sounds, and jugular venous distension
pressure ventilation, and supine positioning. Anesthetic agents,
The presence or suspicion of coronary artery disease, heart barbiturates, and opioids tend to diminish the ventilatory response
failure, untreated hypertension, or significant peripheral vascular to hypercarbia and hypoxia. Endotracheal intubation bypasses the
disease should prompt a specific anesthesiology or cardiology warming and humidifying effects of the upper airway and leads
consultation before surgery. This evaluation could include ECG, to impaired ciliary function, thickened secretions, and subsequent
exercise or chemical stress testing, echocardiography, and/or cardiac decreased resistance to infection. Furthermore, postoperative pain
catheterization as indicated. The result of this consultation should substantially affects a patient’s ability to cough, especially following
determine the surgical and anesthetic risk and should optimize thoracic or abdominal procedures.
the patient’s preoperative cardiovascular status. Furthermore, Preoperatively, the otolaryngologist should elicit:
specific intraoperative and postoperative physiologic (e.g., invasive
monitors) and pharmacologic precautionary measures should be • History of asthma, chronic obstructive pulmonary disease,
delineated, as should the level of postoperative observation. emphysema, pneumonia, pulmonary edema, pulmonary fibrosis,
or adult respiratory distress syndrome, including the number

of hospitalizations and need for intubation or chronic oxygen
Renal 4
therapy The preoperative identification and evaluation of renal problems
• Comorbid diseases that impact pulmonary function, such as are also imperative. Any significant electrolyte abnormalities
congestive heart failure, renal disease, pulmonary hypertension, uncovered during the routine screening of healthy patients should
kyphoscoliosis, obstructive sleep apnea, cystic fibrosis, and be corrected preoperatively, and surgery should be delayed if
neurologic issues impacting respiratory drive additional medical evaluation is warranted. Preexisting renal disease
• Tolerance of prior anesthetics is a major risk factor for the development of acute tubular necrosis
• Use of medications such as steroids, antibiotics, and both during and after surgery. Renal failure, whether acute or
bronchodilators chronic, influences the types, dosages, and intervals of perioperative
• History of tobacco abuse (heavy smokers have a threefold drugs and anesthetics. An oliguric or anuric condition requires
increase in risk of postoperative pulmonary complications.) judicious fluid management, especially in patients with cardiores-
• Symptoms of dyspnea, exercise limitation, cough, hemoptysis, piratory compromise. Furthermore, chronic renal failure (CRF)
and sputum production is often associated with anemia, platelet dysfunction, and coagu-
lopathy. Electrolyte abnormalities, particularly hyperkalemia, can
On physical examination, the clinician should be attuned to lead to arrhythmias, especially in the setting of the chronic metabolic
the patient’s body habitus and general appearance. Obesity, acidosis that often accompanies CRF. Hypertension and accelerated
kyphoscoliosis, and pregnancy can all predispose to poor ventilation, atherosclerosis resulting from CRF are risk factors for developing
atelectasis, and hypoxemia. Cachectic patients are more likely to myocardial ischemia intraoperatively. Blunted sympathetic responses
develop postoperative pneumonia. It should be noted that clubbing may predispose to hypotensive episodes during administration of
and cyanosis, although suggestive, are not reliable indicators of anesthesia. The otolaryngologist must also be wary of the potential
chronic pulmonary disease. The patient’s respiratory rate is for injury to demineralized bones during patient positioning. In
determined, and the presence of accessory muscle use, nasal flaring, addition, an impaired immune system can contribute to poor wound
diaphoresis, or stridor should be documented. Auscultation that healing and postoperative infection. Finally, because patients with
reveals wheezing, rhonchi, diminished breath sounds, crackles, CRF have often received blood transfusions, they are at increased
rales, and altered inspiratory/expiratory time ratios should raise risk of carrying bloodborne pathogens such as hepatitis B and C.
the suspicion of pulmonary compromise. The possible causes of renal disease should be elicited, includ-
In patients with pulmonary disease, preoperative posteroanterior ing hypertension, diabetes, nephrolithiasis, glomerulonephritis,
and lateral chest radiography is mandatory, because findings often polycystic disease, lupus, polyarteritis nodosa, Goodpasture or
direct modification of the anesthetic technique used during surgery. Wegener syndrome, trauma, or previous surgical or anesthetic
Arterial blood gas (ABG) testing on room air is also indicated. insults. The symptoms of polyuria, polydipsia, fatigue, dyspnea,
Patients with an arterial oxygen tension less than 60 mg or an dysuria, hematuria, oliguria or anuria, and peripheral edema are
arterial carbon dioxide tension greater than 50 mg are more likely recorded, as is a complete listing of all medications taken by the
to have postoperative pulmonary complications. Serial ABG patient.
determinations can also be used to assess the overall efficacy of In dialyzed patients, it is important to document the dialysis
preoperative medical and respiratory therapy. As with chest schedule. A nephrologist should assist with the preoperative
radiography, preoperative ABG levels also provide a baseline for evaluation and should optimize the patient’s fluid status and
postoperative comparison. electrolytes before surgery. A nephrologist should also be available
Preoperative pulmonary function tests, such as spirometry and to help manage these issues postoperatively, especially when a
flow-volume loops, can be quite helpful. A quantitative measure major procedure is planned which may require a large volume of
of ventilatory function can also be used to assess the efficacy fluid or blood transfusions intraoperatively.
of both preoperative and surgical interventions. Spirometry Preoperative testing on patients with significant renal disease
can be used to differentiate restrictive from obstructive lung routinely includes ECG, chest radiography, electrolytes and
disease as well as to predict perioperative morbidity from pul- chemistry panel, CBC, PT/PTT, platelet counts, and bleeding
monary complications. In general, a forced expiratory volume times. In addition to a nephrologic consultation, patients with
in 1 second/forced vital capacity ratio of less than 75% is significant renal disease should also receive a preoperative anes-
considered abnormal, whereas a ratio of less than 50% carries thesiology consultation, and further evaluation by a cardiologist
a significant risk of perioperative pulmonary complications. may also be indicated.
Preoperative flow-volume loops can distinguish among fixed A history of benign prostatic hypertrophy or prostate cancer,
(e.g., goiter), variable extrathoracic (e.g., unilateral vocal cord with or without surgery, may predict a difficult urinary tract
paralysis), and variable intrathoracic (e.g., tracheal mass) airway catheterization intraoperatively. Finally, elective surgery should
obstructions. not be performed on patients with acute genitourinary tract infec-
The preoperative management of otolaryngology patients tions, because the potential for urosepsis can be increased by the
with significant pulmonary disease is vital and should follow the transient immunosuppression associated with general anesthesia.
recommendations of a pulmonologist. Smokers are advised to cease
smoking for at least a week before surgery. Chest physiotherapy
aimed at increasing lung volumes and clearing secretions is
Hepatic
instituted. This includes coughing and deep-breathing exercises, Preoperative evaluation of patients with suspected or clinically
incentive spirometry, and chest percussion with postural drain- evident liver failure should begin with a history that details hepa-
age. It is not advisable to operate on a patient with an acute totoxic drug therapy, jaundice, blood transfusion, upper gastro-
exacerbation of pulmonary disease or with an acute pulmonary intestinal bleeding, and previous surgery and anesthesia. The
infection. Acute infections should be cleared with antibiotics physical should include examination for hepatomegaly, splenomegaly,
and chest physiotherapy before elective surgery; prophylactic ascites, jaundice, asterixis, and encephalopathy. The list of blood
antibiotics in noninfected patients are not recommended. Finally, tests is fairly extensive and includes hematocrit, platelet count,
the medical regimen must be optimized, including the use of bilirubin, electrolytes, creatinine, BUN, serum protein, PT/PTT,
inhaled β-adrenergic agonists, cromolyn, and steroids (inhaled serum aminotransferases, alkaline phosphatase, and lactate dehy-
or systemic). Serum levels of theophylline, if used, should be drogenase. A viral hepatitis screen can be obtained as well. Of
therapeutic. note, patients with moderate to severe chronic alcoholic hepatitis
may come to medical attention with relatively normal-appearing that can be used include reserpine and guanethidine, which deplete
liver function tests and coagulation parameters; these patients are catechol stores, and glucocorticoids, which decrease both thyroid
at risk for perioperative liver failure. hormone secretion and T4-to-T3 conversion. Radioactive iodine
Cirrhosis and portal hypertension have wide-ranging systemic also can be used effectively to obliterate thyroid function but
manifestations. Arterial vasodilation and collateralization lead to should not be given to women of childbearing years.
decreased peripheral vascular resistance and increased cardiac The symptoms of hypothyroidism result from inadequate
output. This hyperdynamic state can occur even in the face of circulating levels of T4 and T3 and include lethargy, cognitive
alcoholic cardiomyopathy. The responsiveness of the cardiovascular impairment, and cold intolerance. Clinical findings may include
system to sympathetic discharge and administration of catechols bradycardia, hypotension, hypothermia, hypoventilation, and
is also reduced, likely secondary to increased serum glucagon hyponatremia. No evidence suggests that patients with mild to
levels. Cardiac output can be reduced by the use of propranolol, moderate hypothyroidism are at increased risk for anesthetic
which has been advocated by some as a treatment for esophageal complications, but all elective surgery patients with either condition
varices. By decreasing cardiac output, flow through the portal should be treated with thyroid hormone replacement before surgery.
system and the esophageal variceal collaterals is diminished. In Severe hypothyroidism resulting in myxedema coma is a medical
addition, there is likely a selective splanchnic vasoconstriction. emergency that is associated with a high mortality rate; therefore,
Once initiated, β-blockade cannot be stopped easily because of a IV infusion of T3 or T4 and glucocorticoids should be combined
significant rebound effect. with ventilatory support and temperature control as needed.
Renal sequelae vary with the severity of liver disease, from
mild sodium retention to acute failure associated with the hepa-
torenal syndrome. Diuretics given to decrease ascites can often
Parathyroid Disorders
lead to intravascular hypovolemia, azotemia, hyponatremia, and The prevalence of primary hyperparathyroidism increases with
encephalopathy. Fluid management in the perioperative period age. Of patients with primary hyperparathyroidism, 60% to 70%
should be followed closely, with dialysis instituted as needed for are seen initially with nephrolithiasis secondary to hypercalcemia,
acute renal failure. and 90% are found to have benign parathyroid adenomas. Hyper-
From a hematologic standpoint, patients with cirrhosis often parathyroidism secondary to hyperplasia occurs in association with
have an increased 2,3-diphosphoglycerate level in their erythrocytes, medullary thyroid cancer and pheochromocytoma in multiple
causing a shift to the right of the oxyhemoglobin dissociation endocrine neoplasia type IIA and, more rarely, with malignancy.
curve. Clinically, this results in a lower oxygen saturation. This In humoral hypercalcemia of malignancy, nonendocrine tumors
situation is further compounded by the frequent finding of anemia. have been demonstrated to secrete a parathyroid hormone–like
In addition, significant thrombocytopenia and coagulopathy may protein. Secondary hyperparathyroidism usually results from chronic
be encountered. The preoperative use of appropriate blood products renal disease. The hypocalcemia and hyperphosphatemia associated
can lead to short-term correction of hematologic abnormalities, with this condition lead to increased parathyroid hormone produc-
but the prognosis in these patients remains poor. tion and, over time, to parathyroid hyperplasia. Tertiary hyper-
Encephalopathy stems from insufficient hepatic elimination parathyroidism occurs when the CRF is rapidly corrected, as occurs
of nitrogenous compounds. Although measurements of BUN and in renal transplantation.
serum ammonia levels are useful, they do not always correlate In addition to nephrolithiasis, signs and symptoms of hyper-
with the degree of encephalopathy. Treatment includes hemostasis, calcemia include polyuria, polydipsia, skeletal muscle weakness,
antibiotics, meticulous fluid management, a low-protein diet, and epigastric discomfort, peptic ulceration, and constipation. Radio-
lactulose. graphs may show significant bone resorption in 10% to 15% of
patients. Depression, confusion, and psychosis also may be associated
with marked elevations in serum calcium levels.
Endocrine Immediate treatment of hypercalcemia usually combines sodium
diuresis with a loop diuretic and rehydration with normal saline
Thyroid Disorders as needed. This becomes urgent once the serum calcium levels
Symptoms of hyperthyroidism include weight loss; diarrhea; skeletal rise above 15/dL. Several medications can be used to decrease
muscle weakness; warm, moist skin; heat intolerance; and nervous- serum calcium levels: etidronate inhibits abnormal bone resorption;
ness. Laboratory test results may demonstrate hypercalcemia, the cytotoxic agent mithramycin inhibits parathyroid hormone–
thrombocytopenia, and mild anemia. Elderly patients also can induced osteoclastic activity but is associated with significant side
come to medical attention with heart failure, atrial fibrillation, or effects; and calcitonin works transiently, again by direct inhibition
other dysrhythmias. The term thyroid storm refers to a life- of osteoclast activity. Hemodialysis can also be used in the appropri-
threatening exacerbation of hyperthyroidism that results in severe ate patient population.
tachycardia and hypertension. The most common cause of hypoparathyroidism is iatrogenic.
Treatment of hyperthyroidism attempts to establish a euthyroid Thyroid and parathyroid surgery occasionally results in the
state and to ameliorate systemic symptoms. Propylthiouracil inhibits inadvertent removal of all parathyroid tissue. Ablation of parathyroid
both thyroid hormone synthesis and the peripheral conversion of tissue can also occur after major head and neck surgery and
T4 to T3. Complete clinical response may take up to 8 weeks, postoperative radiation therapy. Symptoms include tetany, perioral
during which the dosage may need to be tailored to prevent and digital paresthesias, muscle spasm, and seizures. A Chvostek
hypothyroidism. Potassium iodide (Lugol solution), which works sign (facial nerve hyperactivity elicited by tapping over the common
by inhibiting iodide organification, can be added to the medical trunk of the nerve as it passes through the parotid gland) and a
regimen. In patients with sympathetic hyperactivity, β-blockers Trousseau sign (finger and wrist spasm after inflation of a blood
have been used effectively. Propranolol has the added benefit of pressure cuff for several minutes) are clinically important indicators
decreasing T4-to-T3 conversion. It should not be used in patients of latent hypocalcemia. Treatment is with calcium supplementation
with CHF secondary to poor left ventricular function or bron- and vitamin D analogues.
chospasm, because it will exacerbate both of these conditions.
Ideally, medical therapy should prepare a mildly thyrotoxic patient
for surgery within 7 to 14 days. If the need for emergency surgery
Adrenal Problems
arises, IV propranolol or esmolol can be administered and titrated Adrenal gland hyperactivity can result from a pituitary adenoma,
to keep the heart rate below 90 beats/min. Other medications an adrenocorticotropic hormone (ACTH)–producing nonendocrine
tumor, or a primary adrenal neoplasm. Symptoms include truncal Conversely, heparin inhibits thrombin and factors IXa, Xa, and
obesity, proximal muscle wasting, “moon” facies, and changes in XIa, elements of the intrinsic clotting pathway. PTT measures 4
behavior that vary from emotional lability to frank psychosis. the effectiveness of the intrinsic and final common pathways.
Diagnosis is made through the dexamethasone suppression test, Relative to the normal population, some patients may demonstrate
and treatment is adrenalectomy or hypophysectomy. It is important significant variation in the quantitative levels of certain factors in
to regulate blood pressure and serum glucose levels and to normalize the absence of clinically relevant clotting abnormalities. Throm-
intravascular volume and electrolytes. Primary aldosteronism (Conn bocytopenia or platelet dysfunction can also lead to derangements
syndrome) results in increased renal tubular exchange of sodium in coagulation. A standard CBC includes a platelet count, which
for potassium and hydrogen ions. This leads to hypokalemia, should be greater than 50,000/µL to 70,000/µL before surgery.
skeletal muscle weakness, fatigue, and acidosis. The aldosterone The Ivy bleeding time, a clinical test of platelet function, should
antagonist spironolactone should be used if the patient requires be between 3 and 8 minutes. Fibrin split products may also be
diuresis. measured to help determine the diagnosis of disseminated intra-
Idiopathic primary adrenal insufficiency (Addison disease) results vascular coagulation.
in both glucocorticoid and mineralocorticoid deficiencies. Symp-
toms include asthenia, weight loss, anorexia, abdominal pain, nausea,
vomiting, diarrhea, constipation, hypotension, and hyperpigmenta-
Congenital Deficiencies of Hemostasis
tion. Hyperpigmentation is caused by overproduction of ACTH Congenital deficiencies of hemostasis affect up to 1% of the
and β-lipotropin, which leads to melanocyte proliferation. Measure- population. The majority of these deficiencies are clinically mild.
ment of plasma cortisol levels 30 and 60 minutes after IV Two of the more serious deficiencies involve factor VIII, which
administration of ACTH aids in diagnosis. Patients with primary is a complex of two subunits, factor VIII:C and factor VIII:von
adrenal insufficiency demonstrate no response. Glucocorticoid Willebrand factor. Gender-linked recessive transmission of defects
replacement is required on a twice-daily basis and should be in the quantity and quality of factor VIII:C leads to hemophilia
increased with stress. Mineralocorticoid therapy can be given once A. Because of its short half-life, perioperative management of
daily. Of note, patients treated for more than 3 weeks with factor VIII:C requires infusion of cryoprecipitate every 8 hours.
exogenous glucocorticoids for any medical condition should be The disease that has a milder presentation than hemophilia A is
assumed to have suppression of their adrenal-pituitary axis and von Willebrand disease, in which bleeding tends to be mucosal
should be treated with stress-dose steroids perioperatively. rather than visceral.
Pheochromocytoma is a tumor of the adrenal medulla that This disease is categorized into three subtypes. Types I and II
secretes both epinephrine and norepinephrine. Of these tumors, represent quantitative and qualitative deficiencies, respectively.
5% are inherited in an autosomal-dominant fashion as part of These deficiencies are passed by autosomal-dominant transmission.
a multiple endocrine neoplasia syndrome. Symptoms include Type I von Willebrand disease also is characterized by low levels
hypertension (which is often episodic), headache, palpitations, of factor VIII:C. Type III von Willebrand disease is much rarer
tremor, and profuse sweating. Preoperative treatment begins with and presents with symptoms similar to those of hemophilia A.
phenoxybenzamine (a long-acting α-blocker) or prazosin at least Because of the longer half-life of factor VIII:von Willebrand factor,
10 days before surgery. A β-blocker is added only after the establish- patients with type II von Willebrand disease can be transfused
ment of α-blockade to avoid unopposed β-mediated vasoconstric- with cryoprecipitate up to 24 hours before surgery, with repeat
tion. Acute hypertensive crises can be managed with nitroprusside infusions every 24 to 48 hours. Patients with type I von Willebrand
or phentolamine. disease require additional transfusion just before surgery to boost
factor VIII:C levels and normalize bleeding time.
Patients with hemophilia, von Willebrand disease, and other
Pancreatic Disorders less common congenital hemostatic anomalies should be followed
Diabetes Mellitus. Diabetes is a disorder of carbohydrate perioperatively by a hematologist. Correction of factor deficiencies
metabolism that results in a wide range of systemic manifestations. should be instituted in a timely fashion, and patients should be
It is the most common endocrine abnormality found in surgical monitored closely for any evidence of bleeding.
patients and can be characterized as either insulin dependent (type Aspirin, an irreversible inhibitor of platelet function, leads to
I, or juvenile onset) or non–insulin dependent (type II). Hyper- prolonged bleeding time. No strong evidence links aspirin therapy
glycemia may result from a variety of etiologies that affect insulin with excessive intraoperative bleeding; however, the theoretical
production and function. Management techniques seek to avoid risk that aspirin and other nonsteroidal anti-inflammatory drugs
hypoglycemia and maintain high-normal serum glucose levels present leads most surgeons to request that their patients stop
throughout the perioperative period. These goals are often difficult taking these medications up to 2 weeks before surgery to allow
to maintain, however, because infection, stress, exogenous steroids, the platelet population to turn over.
and variations in carbohydrate intake can all cause wide fluctuations
in serum glucose levels. Close monitoring is mandatory with
correction of hyperglycemia, using a sliding scale for insulin dosage
Liver Failure
or continuous IV infusion in more severe cases. Fluid management Patients with liver failure can come to medical attention with
should focus on maintaining hydration and electrolyte balance. several hematologic abnormalities. Bleeding from esophageal varices
secondary to portal hypertension can lead to anemia. Hypersplenism
and alcoholic bone marrow suppression can result in serious
Hematologic thrombocytopenia. An elevated prothrombin time (PT) may indicate
A history of easy bruising or excessive bleeding with prior surgery a deficiency in the vitamin K–dependent factors of the extrinsic
should raise suspicion of a possible hematologic diathesis. A clotting pathway, as well as in factors I, V, and XI, which are also
significant number of patients will also come to medical attention produced in the liver. Last, as liver failure progresses, excessive
on anticoagulative therapy for coexisting medical conditions. After fibrinolysis may occur. All of these hematologic sequelae of hepatic
a careful history, the physician should obtain laboratory studies. failure increase the risk of operative morbidity and mortality.
PT, PTT, and platelet count are included in the routine preoperative Preoperative management should attempt to correct anemia and
screen. PT evaluates both the extrinsic and the final common thrombocytopenia as indicated, and to replenish deficient clotting
pathways. Included in the extrinsic pathway are the vitamin K– factors with fresh frozen plasma. Fluid management may prove
dependent factors II, VII, IX, and X, which are inhibited by warfarin. to be a difficult issue.
Another less common cause of PT elevation is the intestinal If the patient has a history of seizures, the surgeon needs to
sterilization syndrome, in which intestinal flora, a major source find out the type, pattern, and frequency of the epilepsy, as well
of vitamin K, are eradicated by prolonged doses of antibiotics in as the current anticonvulsant medications in use and their side
patients unable to obtain vitamin K from other sources. Reversal effects. Phenytoin therapy can lead to poor dentition and anemia,
occurs rapidly with vitamin K therapy. whereas treatment with carbamazepine can cause hepatic dysfunc-
tion, hyponatremia, thrombocytopenia, and leukopenia, all of which
represent concerns for the surgeon and anesthesiologist. Preopera-
Thrombocytopenia tive CBC, liver function tests, and coagulation studies are thus
A decrease in platelet count can occur as a result of a variety of advised. Anesthetic agents such as enflurane, propofol, and lidocaine
medical conditions, including massive transfusion, liver failure, have the potential to precipitate convulsant activity, depending
disseminated intravascular coagulation, aplastic anemia, hematologic on their doses. In general, antiseizure medications must be at
malignancy, and idiopathic thrombocytopenic purpura. With the therapeutic serum levels and should be continued up to and
increasing use of chemotherapeutics for a variety of malignancies, including the day of surgery.
the prevalence of iatrogenic thrombocytopenia has risen. Preop- Symptomatic autonomic dysfunction can contribute to
eratively, the platelet count should be greater than 50,000/µL; at intraoperative hypotension. It may be necessary to augment
levels below 20,000/µL, spontaneous bleeding may occur. In intravascular volume preoperatively through increasing dietary salt
addition, any indication of platelet dysfunction should be evaluated intake, maximizing hydration, and administering fludrocortisone.
with a bleeding time. Severe azotemia secondary to renal failure Additional considerations must be taken into account in patients
may lead to platelet dysfunction (uremic platelet syndrome). Dialysis with upper motor neuron diseases such as amyotrophic lateral
should be performed as necessary. sclerosis or lower motor neuron processes that affect cranial nerve
Correction of thrombocytopenia with platelet transfusion should nuclei in the brainstem. In either case, the otolaryngologist may
preferably come from human leukocyte antigen–matched donors, be confronted with bulbar symptoms such as dysphagia, dysphonia,
particularly in patients who have received prior platelet transfusions, and inefficient mastication. As bulbar impairment progresses, the
and may be sensitized. One unit of platelets contains approximately risk of aspiration increases significantly. When respiratory muscles
5.5 × 1011 platelets. One unit per 10 g of body weight is a good are affected, the patient is likely to have dyspnea, intolerance to
initial dose, and the platelets should be infused rapidly just before lying flat, and an ineffective cough. Coupled with aspiration, these
surgery. factors put the patient at considerable surgical risk for pulmonary
complications. Hence, if surgery is necessary for these patients,
preoperative evaluation should include a pulmonary workup that
Hemoglobinopathies includes chest radiography, pulmonary function tests, and ABG
Of the more than 300 hemoglobinopathies, sickle cell disease and analysis in addition to consultation. A video study of swallowing
thalassemia are by far the most common. Approximately 10% of function may also be indicated. Finally, the patient’s neurologist
blacks in the United States carry the gene for sickle cell anemia, should be closely involved in the decision making (i.e., whether
although the heterozygous state imparts no real anesthetic risk. to proceed with surgery).
Significant clinical manifestations occur in the 1 in 400 blacks Parkinsonism presents the challenges of excessive salivation
who are homozygous for hemoglobin S. The genetic mutation and bronchial secretions, gastroesophageal reflux, obstructive and
results in the substitution of valine for glutamic acid in the sixth central sleep apnea, and autonomic insufficiency, all of which
position of the β-chain of the hemoglobin molecule, leading to predispose to difficult airway and blood pressure management in
alterations in the shape of erythrocytes when the hemoglobin the perioperative period. Dopaminergic medications should be
deoxygenates. The propensity for sickling directly relates to the administered up to the time of surgery to avoid the potentially
quantity of hemoglobin S. Clinical findings include anemia and fatal neuroleptic malignant syndrome. Medications such as phe-
chronic hemolysis, and infarction of multiple organ systems can nothiazines, metoclopramide, and other antidopaminergics should
occur secondary to vessel occlusion. Treatment consists of preventive be avoided. Preoperatively, the patient’s pulmonary function and
measures: oxygenation and hydration help maintain tissue perfusion, autonomic stability should be investigated.
and transfusion before surgical procedures decreases the concentra- If clinically indicated, patients with multiple sclerosis should
tion of erythrocytes that carry hemoglobin S, thereby lowering also undergo full pulmonary evaluation preoperatively, because
the chance of sickling. these patients can come to medical attention with poor respiratory
Multiple types of thalassemia exist, each caused by genetic and bulbar function. The presence of contractures can limit patient
mutations in one of the subunits of the hemoglobin molecule. positioning on the operating table. In addition, the patient must
Symptoms vary with the severity of the mutation. Patients with be free of infection before surgery, because pyrexia can exacerbate
the most severe form, β-thalassemia major, are transfusion depen- the conduction block in demyelinated neurons.
dent, which often leads to iron toxicity. Other thalassemias cause
only mild hemolytic anemia. If transfusion dependency exists, the
patient should be screened carefully for the hepatic and cardiac
CONCLUSION
sequelae of iron toxicity. This chapter provides a brief overview of the importance of
gathering a complete history and performing a thorough physical
examination and preoperative evaluation. Disturbances in one
Neurologic organ system often have repercussions for other systems; an
It is critical to document all neurologic abnormalities. The surgeon interdisciplinary approach that involves the otolaryngologist,
should distinguish peripheral from central lesions, and computed anesthesiologist, primary care physician, and specialized consultants
tomography or magnetic resonance imaging is often helpful in is often warranted. The surgeon’s preoperative discussions with
this regard. Neurologic consultation is sought in the setting of the patient provide a means to reinforce the patient’s postoperative
subtle findings or confusing or paradoxic findings and for evaluation expectations and coping mechanisms. Finally, the responsibility
of possible non-otolaryngologic etiologies of certain complaints, of ensuring an appropriate preoperative evaluation lies with the
such as headache and disequilibrium. During preoperative patient surgeon, and the expediency of this process should be in keeping
counseling, the surgeon must be aware of the potential for nerve with the best interests of the patient.
injury or sacrifice and must communicate the possible sequelae
of these actions to the patient. For a complete list of references, visit ExpertConsult.com.
CHAPTER 4 History, Physical Examination, and the Preoperative Evaluation 48.e1
REFERENCES 6. Sussman GL, Beezhold DH: Allergy to latex rubber, Ann Intern Med
1. Dwamena F, Holmes-Rovner M, Gaulden CM, et al: Interventions 122:43, 1995. 4
for providers to promote a patient-centered approach in clinical 7. Patel PN, et al: Evidence-based use of perioperative antibiotics in
consultations, Cochrane Database Syst Rev (12):CD003267, 2012. otolaryngology, Otolaryngol Head Neck Surg 158:783–800, 2018.
2. Epstein RM, Franks P, Fiscella K, et al: Measuring patient-centered 8. Rechenmacher SJ, Fang JC: Bridging anticoagulation: primum non
communication in patient-physician consultations: theoretical and nocere, J Am Coll Cardiol 66:1392–1403, 2015.
practical issues, Soc Sci Med 61:2005, 1516. 9. Munyon R, et al: 2017 Update in perioperative medicine: 6 questions
3. Hanks G, Cherny NI, Christakis NA, et al, editors: Oxford textbook of answered, Cleve Clin J Med 84:863–872, 2017.
palliative medicine, ed 4, Oxford, 2010, Oxford University Press. 10. Blessberger H, et al: Perioperative beta-blockers for preventing
4. Ng SK, Lee DL, Li AM, et al: Reproducibility of clinical grading of surgery-related mortality and morbidity, Cochrane Database Syst Rev
tonsillar size, Arch Otolaryngol Head Neck Surg 136:159, 2010. (3):CD004476, 2018.
5. Bock M, Fritsch G, Hepner DL: Preoperative laboratory testing, 11. Wilson W, Taubert KA, Gewitz M, et al: Prevention of infective
Anesthesiol Clin 34:43–58, 2016. endocarditis, Circulation 116:1736–1754, 2007.

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PART

4 History, Physical Examination,

KEY POINTS the analysis of whether benefits outweigh potential harms. By

open and close the jaw. Dislocation, locking, or clicking of the

TABLE 4.3 Tuning Fork Testing

Fig. 4.5 Basic anatomy of the anterior neck. Visualize structures

Fig. 4.7 Lymph node regions of the neck.

neurologic examination that is beyond the scope of this chapter,

In a patient who has undergone percutaneous coronary interven-

or adult respiratory distress syndrome, including the number

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