Anesthesia For Head and Neck Surgery

Anesthesia for head and neck surgery - UpToDate 07/09/20 19:58
Official reprint from UpToDate®

www.uptodate.com ©2020 UpToDate, Inc. and/or its affiliates. All Rights Reserved.
Anesthesia for head and neck surgery

Author: Vladimir Nekhendzy, MD
Section Editor: Carin A Hagberg, MD, FASA
Deputy Editor: Marianna Crowley, MD
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Aug 2020. | This topic last updated: Mar 17, 2020.
INTRODUCTION
The spectrum of head and neck (H&N) surgery is broad, ranging from simple procedures such as tonsillectomy to precision laryngologic,
neurotologic, and image-guided skull-base surgery, complex obstructive sleep apnea (OSA) surgery, sophisticated transoral robotic
surgery (TORS), and major H&N cancer surgery with extensive free-flap reconstruction.
This topic will discuss general principles of anesthetic management for H&N surgery, including airway management specific to these
cases. Airway evaluation, management of routine and difficult airways for anesthesia, and anesthesia for tonsillectomy, thyroid surgery,
and tracheal surgery are discussed more fully separately.
● (See "Airway management for induction of general anesthesia".)

● (See "Management of the difficult airway for general anesthesia in adults".)
● (See "Anesthesia for tonsillectomy with or without adenoidectomy in children".)
● (See "Anesthesia for patients with thyroid disease and for patients who undergo thyroid or parathyroid surgery".)
● (See "Anesthesia for tracheal surgery".)
PREOPERATIVE EVALUATION
A medical history and anesthesia-directed physical examination should be performed for all patients who undergo anesthesia. In
anticipation of head and neck (H&N) surgery, we focus the preoperative evaluation on the airway and on those medical conditions that
are associated with complications during these procedures.
Assessment of comorbidities — A number of medical conditions are either more likely or of particular concern for patients who
undergo H&N surgery.
● For patients with uncontrolled hypertension, cerebrovascular disease, coronary artery disease, chronic renal insufficiency, or
advanced liver disease, controlled hypotensive techniques should be avoided, and intraoperative hypotension should be treated
aggressively. (See 'Moderate controlled hypotension' below and "Evaluation of cardiac risk prior to noncardiac surgery" and
"Anesthesia for the patient with liver disease".)
● Patients with lung disease and ventilation/perfusion (V/Q) mismatch may not be suitable candidates for intraoperative ventilation
techniques such as spontaneous ventilation, apneic intermittent ventilation, or jet ventilation. (See 'Ventilation' below and "Evaluation
of preoperative pulmonary risk" and "Anesthesia for patients with chronic obstructive pulmonary disease".)
● Obstructive sleep apnea (OSA) is common among patients who undergo H&N procedures, and may be undiagnosed [1]. Patients
https://www.uptodate.com/contents/anesthesia-for-head-and-neck-surg…earch_result&selectedTitle=1~150&usage_type=default&display_rank=1 Page 1 of 30
with OSA are more sensitive to sedatives and opioids and are predisposed to airway obstruction during induction of anesthesia, on
emergence, and in the postoperative period [2-4]. (See "Intraoperative management of adults with obstructive sleep apnea" and
"Surgical risk and the preoperative evaluation and management of adults with obstructive sleep apnea" and "Postoperative
management of adults with obstructive sleep apnea".)
● Lower cranial nerve involvement in neurotologic patients (cranial nerves X, XI, and XII) may increase the risk of aspiration or airway
obstruction with induction of anesthesia and complicate difficult airway management. (See "Management of the difficult airway for
general anesthesia in adults", section on 'Airway Approach Algorithm'.)
The following issues are of particular concern in patients with H&N cancer:
● Most cases of H&N cancer are associated with tobacco and alcohol use, which predispose patients to cardiopulmonary, liver, and
other comorbidities that may affect anesthetic management.
● Patients with H&N cancers are commonly anemic. Hemoglobin or hematocrit and electrolytes should be measured preoperatively, in
addition to other laboratory tests, as indicated.
● Radiation for H&N cancers can result in dry mouth, airway swelling, dysphagia, poor oral intake, and dehydration, which may
predispose these patients to hypotension with induction of anesthesia. Radiation may also make tracheal intubation and mask
ventilation difficult by causing tissue fibrosis, loss of tissue compliance, restricted mouth opening and neck extension, and glottic and
epiglottic edema [5].
Airway evaluation — Difficulty with airway management is more common for patients who undergo H&N procedures than for many
other surgical patients. Prior anesthesia records should be reviewed, focusing on airway management. Comprehensive preoperative
airway evaluation should include assessment of predictors of difficult/impossible mask ventilation, their association with difficult direct
laryngoscopy (DL), and predictors of difficult videolaryngoscopy (VL).
A history of difficult tracheal intubation is one of the most important predictors of difficult airway management [6-9], though a prior easy
intubation does not guarantee subsequent uneventful airway management in H&N patients, due to progression of the underlying
disease.
Incidence of airway difficulty — Estimates of the incidence of airway difficulty in these patients come from a number of sources.
● For the Fourth National Audit Project (NAP4) from the Royal College of Anaesthetists and the Difficult Airway Society in the United
Kingdom (UK), reports of major airway complications were prospectively collected in nearly three million anesthetized patients
throughout the UK [10]. H&N patients comprised nearly 40 percent of cases with airway management-related complications and
almost 75 percent of cases where emergency surgical airway (ESA) was required for "cannot intubate, cannot ventilate" (CICV)
situations [11,12].
● A higher incidence of ESA in H&N patients was further confirmed in a retrospective study of 452,461 patients in Danish Anaesthesia
Database [13]. In this study, 20 of the 27 patients who required ESA were undergoing ear nose and throat (ENT) surgery and three
additional patients had pathology of the neck or oropharynx. The overall incidence of ESA in ENT patients was recorded at 1.6
events per thousand, which was 27 times higher than in the general surgical population (0.06 per thousand).
● Several large studies have reported that difficult tracheal intubation, defined as three or more attempts at direct laryngoscopy, may
occur in up to 7 to 9 percent of H&N cases [14-16], which is at least two to four times higher than in the mixed surgical population
[17-20].
● H&N cancer patients appear to be at highest risk for difficult airway management among those having H&N surgery. A study of 1200
https://www.uptodate.com/contents/anesthesia-for-head-and-neck-sur…earch_result&selectedTitle=1~150&usage_type=default&display_rank=1 Page 2 of 30
surgical patients reported difficult intubation in 12 percent of H&N cancer patients, compared with 3.5 percent of those who
underwent noncancer H&N surgery and 2 percent of general surgical patients [14]. In NAP4, of the 21 cases of severe airway
difficulty on induction of anesthesia, 13 occurred in patients with upper airway tumors [11].
● The incidence of difficult videolaryngoscopy (VL) may be higher in patients with H&N pathology than in other patients. In a
retrospective review of over 2000 GlideScope intubations, the strongest predictors of GlideScope failure were conditions that are
likely to exist in H&N patients, including prior neck radiation, abnormal neck anatomy, and airway masses (table 1) [21]. Another
study included 300 patients with difficult acute-angle VL (ie, GlideScope or C-Mac with D blade) from among 1100 patients for whom
difficult DL had been predicted. Predictors of difficult VL included the sniffing head position for laryngoscopy (compared with neutral
position), intubation by an attending anesthesiologist, undergoing cardiac or otolaryngologic surgery, and limited mouth opening
[22].
Airway examination — We perform a systematic and comprehensive preoperative airway assessment, starting with a careful history
and the physical characteristics included in the American Society of Anesthesiologists (ASA) 11-point bedside airway assessment tool
(table 2) [23]. While we routinely perform these tests, their value is limited in patients with H&N pathology since they do not account for
risk of aspiration, lower airway problems, the severity of upper airway disease, or base of tongue pathology (eg, lingual tonsillar
hypertrophy), all of which may affect the degree of airway difficulty.
Postradiation changes in the neck and decreased mandibular protrusion are common in patients with H&N pathology, and advanced
disease may make a surgical airway difficult or impossible.
Signs and symptoms of airway obstruction should be elicited, including dyspnea at rest or on exertion, dysphagia, stridor, cough, and
voice changes. A muffled voice may indicate supraglottic disease, whereas glottic lesions often result in a coarse, scratchy voice.
Physical findings may include hoarseness; agitation; and intercostal, suprasternal, and supraclavicular retraction.
Drooling, dysphagia, and expiratory snoring are the signs of marked pharyngeal restriction [24,25], but inspiratory stridor at rest
represents the most worrisome sign, suggesting a reduction in airway diameter at the supraglottic, periglottic, or glottic level of at least
50 percent [26,27].
Airway compromise in H&N patients may also involve the lower airways. Tracheal or tracheobronchial narrowing typically causes
expiratory stridor, whereas biphasic inspiratory-expiratory stridor usually results from obstructive subglottic disease [28].
Special attention should be paid to risk factors for impossible mask ventilation, difficult mask ventilation, and their association
with difficult direct laryngoscopy (table 3 and table 4).
The airway examination and risk factors for difficult airway management are discussed separately (table 1 and table 3 and table 4). (See
"Airway management for induction of general anesthesia", section on 'Airway assessment' and "Management of the difficult airway for
general anesthesia in adults", section on 'Recognition of the difficult airway'.)
Endoscopy and imaging studies — The airway anatomy and extent of disease is usually comprehensively evaluated preoperatively
by routine chest radiography, computed tomography (CT), magnetic resonance imaging (MRI), and flexible nasal laryngoscopy (ie, nasal
endoscopy). The results help define the location, size, spread, and vascularity of obstructive lesions, the degree of obstruction, the
mobility of the vocal cords, and the extent of laryngeal and tracheal deviation or compression [28-30]. In some cases, preoperative
examination of flow-volume loops may be helpful [31]. (See "Evaluation of preoperative pulmonary risk".)
In patients with H&N cancer, airway imaging and nasal endoscopy are required for assessing airway management options, especially if
symptoms of airway obstruction are present [12,32]. For high-risk patients, these results should be reviewed and discussed jointly with
the surgeon [32].
Preoperative nasal endoscopy is routinely performed by the H&N surgeon, but with sufficient practice, preoperative endoscopic airway
evaluation (PEAE) can be performed by the anesthesiologist when necessary. PEAE can provide precise information about the upper
airway and laryngeal anatomy and upper airway dynamics to facilitate formulation of airway management strategy [33]. It can also help
determine the feasibility of supraglottic airway (SGA) placement after induction of general anesthesia. (See 'Supraglottic airways' below.)
SURGICAL CONSIDERATIONS
The plan for anesthesia management for H&N surgery requires especially close coordination with the surgeon (table 5).
● Airway management strategy – For high-risk patients, the strategy for airway management should be formulated with the surgeon,
including review of preoperative imaging studies and endoscopy, selection of airway management device, route for tracheal
intubation (TI), use of jet ventilation, and backup strategies, including preparation for a surgical airway in selected cases. (See
'Airway management strategy' below.)
● Shared airway – The airway is shared by the anesthesiologist and the surgeon during many H&N procedures.
• During oral and intranasal surgery, the airway must be protected from blood, debris, and irrigation fluid; this may require
placement of a throat pack. Endotracheal tubes (ETTs) must be appropriately sized and adequately secured to avoid extubation
or displacement causing a leak of anesthetic gases or oxygen (O2) out of the airway.
• The size and type of ETT should be discussed with the surgeon.
- A 6-mm internal diameter (ID), wire-reinforced, flexible ETT is frequently selected for intraoral surgery.
- Nasal intubation is routinely required for base of the tongue (BOT) surgery, transoral robotic surgery (TORS), orthognathic
surgery, and maxillomandibular advancement (MMA) for obstructive sleep apnea (OSA), and may be requested by the
surgeon for parotidectomy and some dental procedures. A nasal ETT must be appropriately sized to assure adequate
depth of tracheal placement to avoid circuit leak, and must be properly secured to prevent pressure against the nasal ala. A
6-mm ID microlaryngeal tube (MLT) is frequently required to facilitate surgical access for TORS.
- For microlaryngeal surgery, a small-sized ETT (eg, a 5-mm ID MLT) is commonly used. For these cases, the ETT should be
moved to the left corner of the patient's mouth to facilitate introduction of surgical instruments. It must be securely taped to
the lower jaw to avoid outward displacement of the ETT when the mouth is opened and the neck is extended for laryngeal
suspension.
- Specialized laser-safe and nerve integrity monitor (NIM) ETTs may be used for specific procedures.
- Supraglottic airways (SGAs) may be preferred instead of ETTs for many H&N procedures to facilitate smooth emergence
from anesthesia. (See 'Smooth extubation strategy' below.)
• The anesthesia breathing circuit should be configured to allow unrestricted surgical access. As an example, the breathing circuit
should connect to the ETT from the head of the operating table over the top of the patient's head during TORS, orthognathic, or
MMA surgery to allow unrestricted surgical access.
● Still surgical field – Many H&N procedures require a completely still surgical field for precision dissection (eg, otologic and
neurotologic surgery, laser otolaryngologic surgery, functional endoscopic and cranial-base surgery, TORS). For these cases,
patient movement, motion associated with monitoring devices (eg, blood pressure [BP] cuff inflation), and accidental OR table
movements must be avoided. The surgeon should be notified before any action on the part of the anesthesiologist that may interfere
with precision surgery. For precision endoscopic procedures (eg, middle ear surgery), we typically place the BP cuff on the patient's
side opposite the surgeon, to avoid iatrogenic tremor-induced interference with microdissection. (See 'Prevention of patient
movement' below.)
● Neuromonitoring – Neuromonitoring may be used during H&N procedures and may preclude the administration of neuromuscular
blocking agents (NMBAs).
● Fire risk – The risk and prevention of airway fire should be explicitly discussed with the surgeon and operating room nurses
preoperatively, and the "laser time out" should be observed in the OR. Airway fire is a rare but potentially devastating event that may
occur whenever an oxidizing agent (eg, oxygen [O2] or nitrous oxide [N2O]), a fuel source (eg, prep solution, endotracheal tube),
and an ignition source (eg, laser, electrocautery) are present. Airway fire is discussed more fully separately. (See "Fire safety in the
operating room", section on 'General considerations' and "Fire safety in the operating room", section on 'Fire in the airway'.)
ANESTHESIA MANAGEMENT
The objectives and strategies for anesthesia for head and neck (H&N) procedures are shown in a table (table 5).
Choice of anesthetic technique — For most H&N procedures, general anesthesia is the preferred technique. Compared with
monitored anesthesia care (MAC), general anesthesia protects the patient's airway, assures adequate gas exchange, abolishes patient
movement, reliably provides amnesia, and avoids distracting the surgeon.
MAC may be performed for selected H&N procedures. As an example, laryngeal framework surgery may require spontaneous ventilation
and a responsive patient. MAC without immediate access to the patient's airway may be challenging, given the fluctuating level of
surgical stimulation.
Monitoring — Standard American Society of Anesthesiologists (ASA) monitors (eg, blood pressure [BP], electrocardiography, O2
saturation, capnography, and temperature) are usually sufficient during H&N surgery, even when controlled hypotension is used.
Additional monitors may be added as follows:
● Continuous arterial blood pressure monitoring – An intra-arterial catheter should be placed, as required by the patient's medical
condition (eg, significant coronary artery disease [CAD], hypertension, cerebrovascular disease, chronic renal insufficiency [CRI]),
the potential for hemodynamic instability (eg, carotid baroreceptor responses during extensive neck operations, brainstem and
trigeminal reflexes during skull-base and neurotologic procedures), the need for free flap perfusion monitoring, or the expectation of
significant blood loss.
● Central venous catheter – A central venous catheter (CVC) is occasionally placed when there is potential for significant
hemodynamic instability to allow rapid central administration of vasoactive drugs. Central venous pressure (CVP) monitoring is
usually reserved for patients with significant CRI presenting for major and prolonged H&N surgery associated with potentially
significant fluid shifts.
● Processed electroencephalogram – We use processed electroencephalogram (EEG) monitoring to help assess the depth of
anesthesia and to guide anesthetic drug dosing, particularly in the following situations:
• During total intravenous anesthesia (TIVA). (See "Awareness with recall following general anesthesia", section on 'Total
intravenous anesthesia'.)
• For patients with increased sensitivity to anesthetic medications (eg, older or frail patients).
• When neuromuscular blocking agents (NMBAs) are avoided, to assure adequate depth of anesthesia and avoid patient
movement.
Processed EEG monitoring may also be helpful for detecting brain hypoperfusion during intraoperative hypotension or an acute
intracerebral thrombotic event during complex neck dissection.
● Neuromonitoring – If neuromonitoring is used during H&N procedures (eg, electromyographic [EMG] monitoring of facial nerve),
the anesthetic technique may require modification. The effects of anesthetics on neuromonitoring are discussed separately. (See
"Neuromonitoring in surgery and anesthesia".)
Airway management strategy — A successful airway strategy requires a pre-formulated plan for managing failed intubation attempts
and for achieving and maintaining adequate ventilation, oxygenation, and protection against aspiration (algorithm 1 and table 6) [34]. The
optimal airway management approach depends on the surgical procedure, location of the lesion, patient symptoms, acuity of the
situation, and the patient's tolerance of the airway management procedure. It may also be dictated by the anesthesiologist's skill set and
equipment availability.
Patients who undergo complex H&N procedures are most appropriately cared for in high-volume centers with experienced staff that
includes anesthesiologists with special expertise in these cases and complex airway management. A prospective study of 150
intubations in patients with difficult airways due to H&N pathology reported that anesthesiologists specializing in H&N procedures
achieved faster intubation, better patient oxygenation, and fewer airway plan changes than nonspecialist anesthesiologists [15].
The strategy for airway management for high-risk patients should be discussed with the surgeon, who should be present for all aspects
of airway management.
The overall approach to difficult airway management is discussed more fully separately. (See "Management of the difficult airway for
general anesthesia in adults".)
Airway management issues specific to H&N procedures are discussed here.
Laryngoscopy technique — Airway management may deteriorate after single or especially repeated attempts at direct laryngoscopy
(DL), particularly in patients with H&N pathology [11]. H&N tumors can cause airway distortion and can be friable, leading to bleeding,
fragmentation, airway soiling, and rapid edema formation with laryngoscopy. If DL is chosen as a primary approach to tracheal
intubation, multiple attempts should be avoided to avert total airway obstruction.
Videolaryngoscopy (VL) should be strongly considered as the primary intubation technique for H&N patients with predicted difficult DL in
order to increase the chance of first-attempt success. A meta-analysis of randomized controlled trials that compared VL versus DL in
patients with predicted or simulated difficult airways reported improved laryngeal view, more likely successful intubation, and a higher
frequency of first-attempt intubations with VL [35]. (See "Video laryngoscopes and optical stylets for airway management for anesthesia
in adults".)
However, similar to any airway management technique, VL may be difficult or fail, and alternative airway strategies should be planned
(table 1). (See 'Incidence of airway difficulty' above.)
Endotracheal intubation by the surgeon — If DL or VL fails, the surgeon may be able to intubate using the operating laryngoscope
or rigid bronchoscope [23,36-38]. The anterior commissure scope may afford a view of the glottis when other techniques fail, and an
endotracheal tube (ETT) or a bougie introducer can be inserted through its lumen [39].
The surgeon can also use a rigid bronchoscope for ventilation after failed intubation or acute airway obstruction resulting from foreign
bodies, hemoptysis, or tumors [40,41].
Flexible scope intubation — Both awake and asleep flexible scope intubation have relatively high failure rates in patients with H&N
pathology, with reported failure rates between 9 and 60 percent [11,15].
The most common reasons for failure of flexible scope intubation in these patients include inability to identify the glottis, difficulty passing
the scope, bleeding, and airway obstruction [11]. (See "Flexible scope intubation for anesthesia".)
Optical stylets — Optical intubation stylets (eg, Bonfils, Shikani, SensaScope, Clarus Video System) may offer an advantage over
flexible scopes. These rigid devices may bypass mobile supraglottic and glottic masses in situations when a flexible scope will not pass.
(See "Video laryngoscopes and optical stylets for airway management for anesthesia in adults".)
Supraglottic airways — Supraglottic airways (SGAs) may be difficult to insert or seat in patients with H&N pathology. History of neck
radiation; limited mouth opening; and glottic, hypopharyngeal, and subglottic pathology, all of which may be present in these patients, are
predictors of difficulty with SGA ventilation. (See "Management of the difficult airway for general anesthesia in adults", section on
'Recognition of the difficult airway'.)
● Laryngeal mask airways (LMAs) – For H&N surgery, we suggest using a second-generation SGA rather than a first-generation
device in order to improve ventilation and reduce the risk of aspiration. (See "Supraglottic devices (including laryngeal mask
airways) for airway management for anesthesia in adults", section on 'Choice of supraglottic airway'.)
We use a bougie introducer-assisted insertion technique for most second-generation SGAs, and specifically for the LMA ProSeal, to
maximize the first-pass success rate and to assure optimal esophageal and laryngeal seals [42].
The LMA Fastrach, which is an intubating LMA (iLMA), provides excellent ventilation and achieves a 92 to 94 percent success rate
of blind tracheal intubation (TI) in patients with anticipated difficult airways [43,44]. In patients with glottic or infraglottic pathology,
blind TI intubation should be avoided. Instead, a flexible scope can be passed through the iLMA and used to exchange it for an ETT.
(See "Supraglottic devices (including laryngeal mask airways) for airway management for anesthesia in adults", section on 'Use of
flexible intubating scope'.)
● Tubular SGAs – Tubular SGAs, such as the Combitube and laryngeal tubes (LTs), are especially useful in H&N patients with limited
mouth opening or significant upper airway bleeding or regurgitation, when rapid control of the airway is necessary. These devices
are more commonly used in prehospital emergency airway management and in the emergency department (ED). In anesthetized
patients, the LT may provide an advantage over mask ventilation for some patients with H&N pathology. One small study reported
successful ventilation with an LT in 22 of 23 patients with airway tumors, compared with 15 patients who were successfully mask
ventilated [45]. We have successfully used LTs for some patients with small mouth openings and predictors of difficult mask
ventilation for ventilation and as a bridge to tracheal intubation. (See "Extraglottic devices for emergency airway management in
adults", section on 'Combitube'.)
● Use of the SGA as a primary ventilatory device – The use of the SGA in lieu of ETT may be highly preferred for many elective
H&N surgical procedures, such as ear surgery, nasal and intranasal surgery, and facial cosmetic surgery, for which smooth
emergence from anesthesia is essential. (See 'Smooth extubation strategy' below.)
Both retrospective and prospective studies on the use of LMA (or flexible LMA [FLMA]) as a primary ventilatory device in H&N
surgery demonstrate decreased incidence of upper airway trauma and adverse respiratory events, eliminating the need for the use
of NMBAs, improved maintenance of a stable plane of anesthesia and controlled hypotension, and smoother and faster emergence
from anesthesia [46-54].
• For the otologic surgery, we prefer to use a second generation SGA, most commonly LMA-Proseal or LMA-Supreme, to assure
proper SGA positioning and function. (See "Supraglottic devices (including laryngeal mask airways) for airway management for
anesthesia in adults", section on 'Choice of supraglottic airway'.)
The use of these devices does not interfere with the surgical field, as the patient's head is not manipulated until after the end of
surgery for the dressing application.
• For nasal, intranasal, and facial cosmetic surgery we prefer to use FLMA to facilitate surgical access. The properly placed
FLMA creates a reliable oropharyngeal seal, adequately protecting the lower airway from blood, secretions, irrigation fluid, and
surgical debris [55-57], eliminating the need for the use of a throat pack by the surgeon [47,54,58].
• When using SGA as the primary airway for elective H&N surgery, proper device position and function should be confirmed
before surgery starts. Special attention shall be directed to assuring the device's proper positioning and function before the
surgery commences. Safety considerations include standard SGA insertion technique, adequate SGA ventilatory performance,
and adequate airway protection from above and below SGA cuff (ie, adequate airway seal pressure and absent gastric
insufflation during positive pressure ventilation [PPV]). We prefer to use PPV through the SGA (usually, a pressure-controlled
ventilation mode) intraoperatively. (See "Supraglottic devices (including laryngeal mask airways) for airway management for
anesthesia in adults", section on 'Pressure-controlled ventilation'.)
• A retrospective study of 685 patients has demonstrated an overall 92.6 percent success rate of the use of FLMA when the
above strict safety precautions were followed [54].
Combined intubation techniques — The combined use of VL with a flexible scope or optical stylet is increasingly common in
complex airway management. VL provides an enlarged view of the glottis and facilitates manipulation of the flexible scope or optical
stylet in patients with distorted anatomy or airway tumors. The combined technique allows continuous visualization of the intubation
procedure and less chance of tumor disturbance.
Oxygenation strategies — Oxygenation-centered airway management is critical for H&N patients, who present with a higher
incidence of failed tracheal intubation and "cannot intubate, cannot ventilate" (CICV) situations.
The use of high flow nasal oxygen (transnasal humidified rapid insufflation ventilatory exchange [THRIVE]) prolongs apnea time, and
should be strongly considered in anticipated difficult airway management [59,60] (see "Preoxygenation and apneic oxygenation for
airway management for anesthesia", section on 'Transnasal humidified rapid insufflation ventilatory exchange'). The placement of a
transtracheal jet ventilation (TTJV) catheter or cannula before induction of anesthesia for providing tracheal oxygen (O2) insufflation or
high-frequency TTJV [61] can be considered in complex cases.
Alternatively, the Arndt cricothyroidotomy catheter can be placed. Its 3-mm internal diameter (ID) lumen allows ventilation using a low-
pressure gas source, such as an anesthesia breathing circuit or Ambu bag [62].
Surgical airway — A tracheostomy may be planned as the primary intubation strategy for patients who are expected to have
significant airway compromise after surgery.
Most H&N surgeons prefer to perform tracheostomies under controlled conditions, after induction of anesthesia, to avoid airway trauma,
tumor disturbance, and tracheostomy tube displacement or obstruction [15]. The suitability of this plan depends on the predicted difficulty
of airway management after induction of anesthesia.
If awake tracheostomy is deemed necessary, it should be performed under local anesthesia without sedation. An alternative is an awake
dilator cricothyroidotomy [15,63].
For emergency airway management, surgical cricothyroidotomy is strongly preferred over percutaneous access through the cricothyroid
membrane. In the Fourth National Audit Project (NAP4) of airway complications in the United Kingdom, emergency transcutaneous
cannula cricothyroidotomy failed in 60 percent of H&N patients [11,12].
Induction of anesthesia — A variety of medications and techniques can be used for induction of anesthesia and are chosen based on
patient factors.
Intravenous versus inhalation induction — For most adults, intravenous (IV) induction is performed with propofol. Inhalation
induction may be warranted in selected cases but may frequently fail. (See "Induction of general anesthesia: Overview".)
Inhalation induction is of limited value in complex H&N pathology, especially in patients with advanced upper airway obstruction. In the
NAP4, inhalation induction failed in 12 of 16 (75 percent) of H&N patients with compromised airways, and in nearly all these patients (11
of 12), spontaneous ventilation became impossible [11]. (See 'Incidence of airway difficulty' above.)
Inhalation induction should be considered for patients with H&N cancer only after consultation with the surgeon and evaluation of the
predicted difficulty with mask ventilation, and may be best reserved for patients with noncollapsing lesions [15]. Inhalation induction may
be highly problematic for patients with difficult mask ventilation.
Neuromuscular blocking agents — An NMBA is usually administered during induction to facilitate mask ventilation and tracheal
intubation. When neuromonitoring is used, the administration of NMBAs should be avoided intraoperatively. (See "Neuromonitoring in
surgery and anesthesia", section on 'Neuromuscular blocking agents'.)
Positioning — Positioning for H&N surgery requires meticulous attention to detail. General concerns include the following:
● The patient's arms are usually tucked in by the sides. Pressure points should be padded, as should all plastic connectors and the
other parts of IV tubing and monitoring devices to prevent skin pressure and nerve injury.
● The head of the operating table is usually turned 90 or 180 degrees away from the anesthesiologist, preventing immediate access to
the airway. The ETT should be effectively secured to prevent accidental extubation or ETT pullback. The breathing circuit should be
firmly attached to the ETT and supported to prevent disconnection.
● The patient's eyes should be adequately protected. We cover the eyes with occlusive dressing to keep the lids closed and prevent
skin preparation solution from entering the eyes. In addition, protective goggles should be placed for surgeries involving heavy
instrumentation around the patient's face (eg, during transoral robotic surgery).
● The operating table may be placed in a steep lateral position during otologic and neurotologic surgery. We apply three straps, one
each over the chest, pelvis, and legs, to prevent patient shifting on the operating table.
Maintenance of anesthesia — Many H&N procedures involve delicate surgery on complex, reflexogenic anatomy. A variety of
inhalation and IV anesthetic agents may be administered, with the following goals:
● Maintenance of a stable plane of anesthesia during varying degrees of stimulation

● Minimizing bleeding to maintain a clear, dry surgical field
● Maintenance of a still surgical field
● Prevention of postoperative nausea and vomiting (PONV)
● Planning for smooth emergence
● Preparation for rapid recovery and fast-track discharge, where appropriate
Choice of anesthetic agents — Inhalation anesthetics, IV anesthetics, and a combination of both classes of anesthetic agents may
be administered for the maintenance of anesthesia for H&N surgery. For patients at high risk of postoperative nausea and vomiting
(PONV), and for those who undergo H&N procedures that are particularly emetogenic (eg, middle ear surgery, neurotologic surgery),
propofol-based anesthesia may reduce the incidence of PONV. Our technique of choice for most H&N procedures is total intravenous
anesthesia (TIVA) using target-controlled infusion (TCI) of propofol and opioids. Others use alternative techniques.
Total intravenous anesthesia — We prefer TIVA with propofol and an opioid with intraoperative processed EEG monitoring for
most H&N procedures. For most surgical procedures that are associated with mild-to-moderate postoperative pain (table 7), TCI with
propofol 3 to 3.5 mcg/mL and remifentanil 2 to 5 ng/mL should be appropriate, especially if neuromuscular block is maintained or if an
LMA is used [64-67]. Doses should be modified for older patients and for patients with comorbidities.
Advantages of this technique include the following:
● The synergism between propofol and opioid (ie, remifentanil, sufentanil, fentanyl, and alfentanil) allows quick titration of anesthesia
to the desired clinical effect [68,69].
● TIVA with propofol/opioid facilitates intraoperative hemodynamic control and rapid recovery from anesthesia.
● TIVA with propofol/opioid produces profound depression of pharyngeal and laryngeal reflexes and muscle tone [70] and suppresses
the hormonal stress response to H&N surgical procedures [71], thereby facilitating induced hypotension. (See 'Moderate controlled
hypotension' below.)
● Compared with inhalation anesthesia, TIVA may result in faster early recovery after surgery and a reduction in PONV [55,72-76].
● TIVA is almost always used during jet ventilation or an intermittent apnea technique for laryngologic surgery.
TCI technology is not available in the United States.
Opioids during maintenance of anesthesia — We administer opioids by infusion during H&N surgery as an integral component
of anesthesia maintenance. We choose the drug and dose based on the expected degree of intraoperative stimulation and postoperative
pain, duration of surgery, patient factors (eg, opioid-naïve or not), and the individual surgical technique (table 7).
The advantages of opioid-based anesthetic techniques for these patients include the following (table 8):
● Suppresses airway reflexes

● Decreases requirement for other anesthetic agents
● Aids controlled hypotension
● Decreases patient movement
● Facilitates processed EEG monitoring
● Facilitates neuromonitoring
● Allows smooth emergence from anesthesia
● Improves postoperative pain control
Continuous opioid infusion may decrease the total dose of opioid administered and improve hemodynamic stability compared with
intermittent boluses [64,77,78].
Remifentanil is an ultrashort-acting opioid that can be administered at high doses to achieve profound intraoperative analgesia without
postoperative residual effects [56]. Compared with fentanyl [57] and alfentanil [79-82], remifentanil may result in increased hemodynamic
stability and faster recovery from anesthesia. The choice of opioids, stratification according to the surgical procedure, and infusion doses
are shown in a table (table 7) [55,57,64,68,72,79,83-99]. (See "Perioperative uses of intravenous opioids in adults".)
Inhalation anesthetics — When inhalation anesthesia is used, sevoflurane may be preferred for outpatient surgery compared
with desflurane and isoflurane. Sevoflurane is less of an airway irritant and is associated with less postoperative coughing than
desflurane [100,101], and early recovery from anesthesia may be more rapid with sevoflurane than it is with isoflurane [84,101].
Inhalation anesthetics are associated with increased PONV compared with propofol-based anesthesia. We routinely administer
multimodal prophylaxis for PONV for all patients who undergo H&N surgery. (See 'Prophylaxis for postoperative nausea and vomiting'
below.)
If nitrous oxide (N2O) is indicated clinically, its use should be discussed with the surgeon during middle ear procedures. N2O diffuses into
closed spaces, including the middle ear in patients with eustachian tube dysfunction, and can displace tympanic grafts and other middle
ear structures [102]. N2O also supports combustion and should be avoided when airway fire risk is high. (See "Fire safety in the
operating room", section on 'Preventive measures in high-risk procedures'.)
Moderate controlled hypotension — Controlled hypotension (ie, systolic blood pressure [BP] below 100 mmHg or mean arterial
pressure of 60 to 70 mmHg) is desirable for many H&N procedures (eg, middle ear surgery, neck dissection, endoscopic procedures,
etc) to maintain a bloodless surgical field. The need for controlled hypotension and the goal BP should be discussed with the surgeon,
considering patient comorbidities. Controlled hypotension should be avoided in patients with uncontrolled hypertension, cerebrovascular
disease, significant coronary artery disease, chronic renal insufficiency, or advanced liver disease.
A variety of medications can be administered to induce hypotension. In practice, remifentanil infusion with either propofol or inhalation
anesthesia usually results in the desired degree of hypotension without administration of vasoactive medications [103,104]. The
incidence of rebound hypertension and tachycardia with the use of remifentanil appears to be low.
Other medications that have been used to induce hypotension during H&N surgery include sodium nitroprusside, beta blockers (eg,
esmolol, labetalol, metoprolol), calcium channel blockers (eg, nicardipine), alpha2-adrenoreceptor agonists (eg, dexmedetomidine),
magnesium sulfate, and potent inhalation anesthetics (eg, sevoflurane, isoflurane, desflurane) [67,103-107].
Prevention of patient movement — NMBAs may be administered to prevent patient movement during many delicate H&N
procedures. When NMBAs must be avoided (eg, neuromonitoring), deeper anesthesia is usually required to prevent patient movement.
Highly titratable opioid infusion (eg, remifentanil) can help maintain a stable level of anesthesia without affecting neuromonitoring. (See
'Opioids during maintenance of anesthesia' above.)
Facial nerve monitoring is often used during craniofacial, middle ear, and skull-base surgery. Facial nerve electromyographic (FNEMG)
monitoring used by the surgeon may alert the anesthesiologist to a decrease in anesthetic depth and may predict patient movement
[85,108]. A study including 60 patients who underwent craniofacial or skull-base surgery reported that FNEMG changes predicted patient
movement better than changes in the bispectral index (BIS; processed EEG) monitor [85].
Ventilation — Several specialized ventilation strategies can be used to improve surgical access during laryngologic surgery.
Supraglottic, infraglottic, transtracheal jet ventilation (TTJV), and apneic intermittent ventilation are some of the possibilities.
Jet ventilation — Both low- and high-frequency jet ventilation (HFJV) can be used for laryngologic surgery, depending on JV
technique (below). HFJV is utilized more often in general, and is used exclusively for infraglottic and transtracheal routes. HFJV is
usually initially set at 150 counts/minute (CPM; range 100 to 300 CPM), delivering tidal volumes as small as 1 to 3 mL/kg. HFJV results
in minimal laryngeal motion and a quiet surgical field without the need to interrupt ventilation. However, carbon dioxide (CO2) retention is
possible since dead space ventilation is increased compared with lower-frequency, higher-tidal-volume ventilation.
JV requires meticulous attention to detail and familiarity with the specialized equipment in order to avoid barotrauma. In particular, airway
patency must be continuously maintained to allow exhalation.
JV can be performed with infraglottic, supraglottic, or transtracheal techniques.
● Infraglottic JV – Infraglottic JV is used most commonly for airway surgery. A 3- to 4-mm outer diameter (OD), laser-resistant double
lumen catheter or a metal jet cannula is placed in the trachea using laryngoscopy [109-113]. End-tidal CO2 (ETCO2) can be
intermittently monitored via one of the catheter lumens. Infraglottic JV can also be used through a rigid bronchoscope deployed to
bypass obstructing airway lesions, or for rescue ventilation.
● Supraglottic JV – For supraglottic JV, the jet nozzle is positioned above the glottic opening, resulting in a very low risk of
barotrauma. Supraglottic JV is usually administered through the operating laryngoscope deployed by surgeon, and provides a
completely unobstructed view of the larynx. However, the movement of the vocal cords is increased compared with the infraglottic
approach, and ETCO2 cannot be measured. The jet must be directed precisely at the glottis for effective, safe ventilation.
● Transtracheal JV – The larynx is bypassed from below by a long catheter or Ravussin-type cannula placed through the cricothyroid
membrane [110,112,114].
THRIVE — Many conventional, non-laser laryngologic surgical procedures up to 30 to 40 minute duration can be performed on
selected patients using transnasal humidified rapid insufflation ventilatory exchange (THRIVE) as the primary ventilatory technique.
THRIVE provides both apneic oxygenation and apneic ventilation (a certain degree of CO2 elimination), and affords the surgeon with a
fully enlarged, completely unobstructed and still surgical filed [59,115-121]. This greatly facilitates surgical access, with a potential to
improve patient outcomes [115]. A close communication between the surgeon and the anesthesiologist is required during THRIVE, and
the use of this technique may be best reserved, at least initially, to dedicated H&N anesthesia team(s). (See "Preoxygenation and apneic
oxygenation for airway management for anesthesia", section on 'THRIVE for laryngologic surgery' and "Anesthesia for laryngeal
surgery", section on 'THRIVE'.)
Intermittent apneic ventilation — With this technique, ETT is intermittently removed and replaced by the surgeon through the
lumen of the operating laryngoscope, to allow surgery on still and unobstructed airway structures.
Prophylaxis for postoperative nausea and vomiting — Patients who undergo H&N surgery should receive aggressive prophylaxis
for PONV and postdischarge nausea and vomiting (PDNV). Retching and vomiting can increase venous pressure in the H&N and result
in postoperative bleeding, hematoma formation, and graft disruption. We use a multimodal approach to prophylaxis, consisting of TIVA
with intraoperative 5-HT3 antagonist (eg, ondansetron 4 to 8 mg IV), dexamethasone (8 to 10 mg IV), and multimodal pain control to
minimize opioid requirement. We place a scopolamine patch for particularly high-risk patients. (See "Postoperative nausea and
vomiting".)
Plan for postoperative pain control — The plan for control of postoperative pain begins intraoperatively, and in some cases,
preoperatively. In our practice, intraoperative opioid choice and administration is largely based on the expected degree of postoperative
pain (table 7).
A multimodal approach to pain control helps to minimize the use of postoperative opioids, and may include perioperative use of
acetaminophen and/or gabapentin, and nonsteroidal antiinflammatory drugs (NSAIDs). (See "Management of acute perioperative pain"
and 'Opioids during maintenance of anesthesia' above.)
In some cases, local anesthetic infiltration or peripheral nerve blocks may be used for H&N cases for postoperative pain control.
Emergence from anesthesia — Emergence from anesthesia for H&N patients should include a smooth, rapid awakening and
extubation, devoid of coughing, bucking, and straining. BP should be controlled during emergence and in the immediate postoperative
period for many H&N procedures.
Extubation plan — Endotracheal extubation should be planned as thoroughly as endotracheal intubation, and requires an explicit
strategy for patients who undergo H&N procedures.
Compared with other elective surgeries, H&N surgeries are associated with higher rates of complications during and immediately after
emergence and planned extubation, including [122]:
● Laryngospasm
● Postextubation airway edema
● Postoperative airway obstruction
● Need for reintubation
One-third of adverse events reported to the NAP4 occurred during emergence and recovery from anesthesia [123]. (See 'Incidence of
airway difficulty' above.)
An approach to extubation is outlined in extubation algorithms from the Difficult Airway Society in the United Kingdom (algorithm 2A-C)
[124]. A strategy for extubation is also recommended in the ASA Practice Guidelines for Management of the Difficult Airway, and is
consistent with our approach to extubation of H&N patients [23].
The plan for extubation should be formulated with the surgeon and should consider the difficulty of initial intubation, the extent and
duration of surgery, the potential for postoperative swelling or bleeding, and the patient's current and preoperative medical status.
Extubation may be delayed for patients who are predicted to be at high risk of failed extubation, and these patients should be transported
to an intensive care unit (ICU) for further treatment. If a trial of extubation is considered for high-risk patients, all necessary equipment
and personnel should be available for potential reintubation or establishment of a surgical airway. In this setting, we extubate over an
airway exchange catheter.
Extubation of patients with a difficult airway and the use of the airway exchange catheter are discussed more fully separately. (See
"Management of the difficult airway for general anesthesia in adults", section on 'Extubation'.)
Smooth extubation strategy — Extubation should occur when airway protective reflexes have returned, with the goal of preventing
coughing and straining. Strategies for smooth emergence and extubation include the following:
● The use of the SGA as a primary ventilatory device, in lieu of ETT. (See 'Supraglottic airways' above.)
● The Bailey maneuver – This technique provides airway support with an SGA (usually, an LMA) for emergence after removal of the
ETT at a deep level of anesthesia [125]. The LMA is less stimulating to the airway and facilitates smooth emergence from
anesthesia. For the Bailey maneuver, the LMA is placed behind the in-situ ETT, its cuff is inflated, the patient's airway is suctioned,
and the ETT is removed. The ETT keeps the epiglottis out of the way of LMA insertion against the palatopharyngeal curve. The
airway is then managed with the LMA until the patient awakens from anesthesia.
● Remifentanil during emergence – Remifentanil infusion (eg, 0.03 to 0.08 mcg/kg/minute) can be continued during emergence from
anesthesia to reduce cough and the hemodynamic changes associated with tracheal extubation [126]. Remifentanil provides a
predictable, rapid, and almost simultaneous recovery of consciousness and protective airway reflexes.
● Antihypertensives – We prophylactically administer labetalol (0.1 to 0.3 mg/kg IV) at the end of surgery for hypertensive patients to
avoid hypertension on emergence.
POSTOPERATIVE CARE
Many head and neck (H&N) procedures are performed on an ambulatory basis, and patients are discharged home after recovery from
anesthesia. Multimodal strategies for postoperative pain control and postoperative nausea and vomiting (PONV) and postdischarge
nausea and vomiting (PDNV) prophylaxis should be used for patient comfort and for fast-tracking ambulatory H&N surgical patients.
The disposition (ie, recovery room versus intensive care unit [ICU]) for patients who have had major H&N surgery should be determined
by the need to delay extubation or monitor airway status, and medical concerns.
SUMMARY AND RECOMMENDATIONS
● Difficulty with airway management is more common for patients who undergo head and neck (H&N) procedures than for many
other surgical patients. Comprehensive preoperative airway evaluation should include assessment of predictors of
difficult/impossible mask ventilation, their association with difficult direct laryngoscopy (DL), predictors of difficult videolaryngoscopy
(VL), preoperative nasal endoscopy findings, and the results of imaging studies (table 1 and table 3 and table 4). (See 'Airway
evaluation' above.)
● Anesthesia for H&N procedures requires close coordination with the surgeon, including airway management and extubation
strategies, the need for a dry and still surgical field, and considerations for the use of neuromonitoring. (See 'Surgical considerations'
above.)
● General anesthesia is the preferred technique for most H&N procedures. Monitored anesthesia care may be used for select cases.
(See 'Choice of anesthetic technique' above.)
● The strategy for airway management should include a predetermined set of sequential plans for managing failure of the previous
attempts. Airway management concerns that apply specifically to patients with H&N pathology include the following (see 'Airway
management strategy' above):
• Difficulty with airway management should be expected for many H&N patients during induction and emergence from
anesthesia.
• For anticipated difficult airway, advanced oxygenation techniques such as transnasal humidified rapid insufflation ventilatory
exchange (THRIVE) should be strongly considered prior to and during induction of anesthesia and during intubation attempts.
(See 'Oxygenation strategies' above.)
• VL should be strongly considered as the primary intubation technique for many of these patients. Repeated attempts at DL
should be avoided, and limited to two. (See 'Laryngoscopy technique' above.)
• Inhalation induction has a high failure rate in patients with complex H&N pathology and should be considered in close
cooperation with the surgeon. (See 'Intravenous versus inhalation induction' above.)
• Flexible scope intubation may fail in patients with H&N pathology because of difficulty in identifying the glottis, difficulty passing
the scope or endotracheal tube (ETT), and bleeding. The combination of a flexible scope with a VL or optical stylet offers a wide
view of the glottis and continuous visualization throughout intubation. (See 'Flexible scope intubation' above and 'Combined
intubation techniques' above.)
• Rigid optical stylets may be used to bypass mobile supraglottic and glottic masses. (See 'Optical stylets' above.)
• Supraglottic airways (SGAs) can be used as primary ventilatory devices for selected patients who undergo H&N surgery, and
may also be used for ventilation as a bridge to tracheal intubation. We suggest using a second-generation SGA for these
patients (Grade 2C). (See 'Supraglottic airways' above.)
• If DL or VL fails, the surgeon may be able to intubate using the operative laryngoscope or rigid bronchoscope. (See
'Endotracheal intubation by the surgeon' above.)
• A tracheostomy may be the primary form of airway management and may be performed awake or after induction of anesthesia.
(See 'Surgical airway' above.)
● Our preferred technique for anesthesia for H&N procedures is total intravenous anesthesia (TIVA) with propofol and opioid infusions,
with processed EEG monitoring. (See 'Choice of anesthetic agents' above.)
● We administer opioid infusions as an integral part of the anesthetic technique, with doses stratified according to the surgical
stimulus, duration of surgery, and expected degree of postoperative pain. Opioid infusions facilitate maintenance of controlled
hypotension, suppress airway reflexes, minimize patient movement without the use of neuromuscular blocking agents (NMBAs), and
facilitate smooth emergence from anesthesia (table 7). (See 'Opioids during maintenance of anesthesia' above.)
● Jet ventilation (JV) or apneic intermittent ventilation may be required for a variety of laryngologic procedures. THRIVE can be used
effectively and successfully for selected patients undergoing laryngologic surgery. (See 'Ventilation' above.)
● We administer multimodal prophylaxis for postoperative nausea and vomiting (PONV) for all patients who undergo H&N procedures.
(See 'Prophylaxis for postoperative nausea and vomiting' above.)
● The goals for emergence from anesthesia should include a smooth awakening and extubation without coughing, straining, or
retching, to avoid venous congestion and bleeding. When indicated, the plan for extubation should be formulated with the surgeon
and should reflect the expected risk for postoperative airway complications. (See 'Extubation plan' above.)
Use of UpToDate is subject to the Subscription and License Agreement.
Topic 94228 Version 13.0
GRAPHICS
Predictors of difficult videolaryngoscopy
Otolaryngologic and cardiac surgery
Sniffing head positioning
Abnormal neck anatomy (a neck scar, a neck mass, neck radiation changes)
Decreased cervical spine motion
Decreased oral entry (obesity, decreased mouth opening, decreased jaw mobility)
Restricted oropharyngeal space (edema, bleeding, retrognathia)
Prepared with data from:

1. Aziz MF, Bayman EO, Van Tienderen MM, et al. Predictors of difficult videolaryngoscopy with GlideScope® or C-MAC® with D-blade: secondary analysis from a
large comparative videolaryngoscopy trial. Br J Anaesth 2016; 117:118.
2. Stroumpoulis K, Pagoulatou A, Violari M, et al. Videolaryngoscopy in the management of the difficult airway: a comparison with the Macintosh blade. Eur J
Anaesthesiol 2009; 26:218.
3. Asai T, Liu EH, Matsumoto S, et al. Use of the Pentax-AWS in 293 patients with difficult airways. Anesthesiology 2009; 110:898.
4. Aziz MF, Healy D, Kheterpal S, et al. Routine clinical practice effectiveness of the Glidescope in difficult airway management: an analysis of 2,004 Glidescope
intubations, complications, and failures from two institutions. Anesthesiology 2011; 114:34.
5. Lai HY, Chen IH, Chen A, et al. The use of the GlideScope for tracheal intubation in patients with ankylosing spondylitis. Br J Anaesth 2006; 97:419.
6. Tremblay MH, Williams S, Robitaille A, Drolet P. Poor visualization during direct laryngoscopy and high upper lip bite test score are predictors of difficult
intubation with the GlideScope videolaryngoscope. Anesth Analg 2008; 106:1495.
7. Savoldelli GL, Schiffer E, Abegg C, et al. Comparison of the Glidescope, the McGrath, the Airtraq and the Macintosh laryngoscopes in simulated difficult airways.
Anaesthesia 2008; 63:1358.
8. Narang AT, Oldeg PF, Medzon R, et al. Comparison of intubation success of video laryngoscopy versus direct laryngoscopy in the difficult airway using high-
fidelity simulation. Simul Healthc 2009; 4:160.
Courtesy of Dr. Vladimir Nekhendzy.
Graphic 108798 Version 4.0
Components of the preoperative airway physical examination
Airway examination component Nonreassuring findings
Length of upper incisors Relatively long
Relationship of maxillary and mandibular incisors during normal jaw closure Prominent "overbite" (maxillary incisors anterior to mandibular incisors)
Relationship of maxillary and mandibular incisors during voluntary protrusion of Patient cannot bring mandibular incisors anterior to (in front of) maxillary
mandible incisors
Interincisor distance Less than 3 cm
Visibility of uvula Not visible when tongue is protruded with patient in sitting position (eg,
Mallampati class >2)
Shape of palate Highly arched or very narrow
Compliance of mandibular space Stiff, indurated, occupied by mass, or non-resilient
Thyromental distance Less than three ordinary finger-breadths
Length of neck Short
Thickness of neck Thick
Range of motion of head and neck Patient cannot touch tip of chin to chest or cannot extend neck
This table displays some findings of the airway physical examination that may suggest the presence of a difficult intubation. The decision to examine some
or all of the airway components shown on this table is dependent on the clinical context and judgment of the practitioner. The table is not intended as a
mandatory or exhaustive list of the components of an airway examination. The order of presentation in this table follows the "line of sight" that occurs
during conventional oral laryngoscopy.
From: Apfelbaum JL, Hagberg CA, Caplan RA, et al. Practice guidelines for management of the difficult airway: an updated report by the American Society of
Anesthesiologists Task Force on Management of the Difficult Airway. Anesthesiology 2013; 118:251. DOI: 10.1097/ALN.0b013e31827773b2. Copyright © 2013
American Society of Anesthesiologists. Reproduced with permission from Wolters Kluwer Health. Unauthorized reproduction of this material is prohibited.
Predictors of difficult and impossible mask ventilation
Difficult mask ventilation Impossible mask ventilation
Mallampati grade 3 to 4 Mallampati grade 3 to 4

Decreased mandibular protrusion Male sex
Presence of beard Presence of beard
Obesity (BMI ≥30) OSA*
Age >57 years Neck radiation changes
Lack of teeth
History of snoring
At least three predictors should be present in each category for a reasonably high probability of the event.
BMI: body mass index; OSA: obstructive sleep apnea; CPAP: continuous positive airway pressure; BiPAP: bilevel positive airway pressure.
* Moderate-to-severe OSA, associated with the use of CPAP/BiPAP or a history of OSA surgery.
Adapted from:
1. Langeron O, Masso E, Huraux C, et al. Prediction of difficult mask ventilation. Anesthesiology 2000; 92:1229.
2. Kheterpal S, Han R, Tremper KK, et al. Incidence and predictors of difficult and impossible mask ventilation. Anesthesiology 2006; 105:885.
3. Kheterpal S, Martin L, Shanks AM, Tremper KK. Prediction and outcomes of impossible mask ventilation: a review of 50,000 anesthetics. Anesthesiology 2009;
110:891.
Predictors of combined difficulty with mask ventilation and direct laryngoscopy
Predictors of difficult/impossible mask ventilation Modified and additional predictors
Mallampati grade 3 to 4 Age ≥46 years

Decreased mandibular protrusion Presence of teeth
Presence of beard Neck radiation changes or a neck mass
Obesity (BMI ≥30) Thick or obese neck
Male sex Unstable neck or decreased neck extension
OSA* Decreased thyromental distance
The association of DMV with difficult DL includes many predictors of DMV and impossible mask ventilation, as well as the modified and additional factors,
listed in italics. At least five predictors (risk factors) total should be present for a reasonably high probability of both DMV and difficult DL. Class III
patients (five risk factors) comprise 5 percent of all DMV+DL cases, and patients from Classes IV (six risk factors) and V (7 to 11 risk factors) comprise
the largest group (85 percent) of these cases.
DL: direct laryngoscopy; BMI: body mass index; OSA: obstructive sleep apnea; DMV: difficult mask ventilation; CPAP: continuous positive airway pressure; BiPAP:
bilevel positive airway pressure.
* Moderate-to-severe OSA associated with the use of CPAP/BiPAP or a history of OSA surgery.
Adapted from: Kheterpal S, Healy D, Aziz MF, et al. Incidence, predictors, and outcome of difficult mask ventilation combined with difficult laryngoscopy: a report from
the multicenter perioperative outcomes group. Anesthesiology 2013; 119:1360.
Objectives and strategies for anesthesia for head and neck surgery
Expert airway management

Shared airway precautions
Surgery-specific airway management requirements
Versatility with difficult airway devices and techniques
Proficiency with different ventilation techniques and strategies
Team-centered approach
Provision of a stable plane of anesthesia and a clear surgical field

Opioid-based techniques
TIVA
Moderate controlled hypotension
Hypnotic monitoring
Immobility of the surgical field
Absence of patient movement
Avoidance of iatrogenic motion interference
Smooth and rapid emergence from anesthesia

Remifentanil emergence
Bailey maneuver
SGA as the primary ventilatory device
Fast-tracking patients for discharge

Stratified opioid use
Multimodal analgesia
Adjuvant techniques
Prophylaxis of PONV
TIVA: total intravenous anesthesia; SGA: supraglottic airway device; PONV: postoperative nausea and vomiting.
https://www.uptodate.com/contents/anesthesia-for-head-and-neck-sur…arch_result&selectedTitle=1~150&usage_type=default&display_rank=1 Page 20 of 30
American Society of Anesthesiologists difficult airway algorithm
SGA: supraglottic airway; LMA: laryngeal mask airway; ILMA: intubating laryngeal mask airway.
* Confirm ventilation, tracheal intubation, or SGA placement with exhaled CO 2 .
¶ Invasive airway access includes surgical or percutaneous airway, jet ventilation, and retrograde intubation.
Δ Other options include (but are not limited to): surgery utilizing face mask or supraglottic airway (SGA) anesthesia (eg, LMA, ILMA, laryngeal tube),
local anesthesia infiltration, or regional nerve blockade. Pursuit of these options usually implies that mask ventilation will not be problematic.
Therefore, these options may be of limited value if this step in the algorithm has been reached via the Emergency Pathway.
◊ Alternative difficult intubation approaches include (but are not limited to): video-assisted laryngoscopy, alternative laryngoscope blades, SGA (eg,
LMA or ILMA) as an intubation conduit (with or without fiberoptic guidance), fiberoptic intubation, intubating stylet or tube changer, light wand, and
blind oral or nasal intubation.
§ Emergency noninvasive airway ventilation consists of a SGA.
¥ Consider re-preparation of the patient for awake intubation or canceling surgery.
Reproduced with permission from: Apfelbaum JL, Hagberg CA, Caplan RA, et al. Practice guidelines for management of the difficult airway: an updated
report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Anesthesiology 2013; 118:251. DOI:
10.1097/ALN.0b013e31827773b2. Copyright © 2013 by the American Society of Anesthesiologists, Inc. Unauthorized reproduction of this material is
prohibited.
Airway management considerations for head and neck surgery
Expert airway management

Shared airway precautions and coordination with surgeon
Surgery-specific airway management requirements
Versatility with difficult airway devices and techniques
Versatility with different ventilatory techniques and strategies
Team-centered approach
Airway management during induction of anesthesia

Increased risks of:
Difficult airway management
Airway management failure
Need for emergency airway management
Airway management during extubation

Extubation strategies – Increased risks of:
Laryngospasm
Postextubation airway edema
Postoperative airway obstruction
Reintubation
Requirement for smooth extubation
Stratification and doses of opioids for head and neck procedures
Stratification of opioid infusions for head and neck surgery
Degree of postoperative pain Opioid regimen
None to mild Remifentanil infusion +/– fentanyl 1 mcg/kg total dose
Mild to moderate Remifentanil infusion + fentanyl 1 to 3 mcg/kg total dose

OR
Alfentanil infusion
Moderate to severe Sufentanil infusion +/– remifentanil infusion*

OR
Fentanyl infusion +/– remifentanil infusion*
Opioid doses for head and neck surgery ¶ [1-23]
Opioid IV load IV infusion
Fentanyl 3 to 7 mcg/kg Δ 0.7 to 2.5 mcg/kg/hour ◊
Sufentanil 0.25 to 1.5 mcg/kg Δ 0.2 to 0.3 mcg/kg/hour

TCI: 0.4 to 0.5 ng/mL TCI: 0.2 to 0.65 ng/mL
Alfentanil 20 to 40 mcg/kg 0.25 to 1.5 mcg/kg/minute

TCI: 100 to 200 ng/mL TCI: 60 to 150 ng/mL
Remifentanil 0.5 to 2 mcg/kg 0.05 to 0.3 mcg/kg/minute

TCI: 4 ng/mL TCI: 1.5 to 9 ng/mL
TCI with opioids and propofol allows for easier and more rapid titration of drugs to patient responses and facilitates intraoperative hemodynamic control,
as well as rapid recovery from anesthesia.
IV: intravenous; TCI: target-controlled infusion; TIVA: total IV anesthesia; N 2 O: nitrous oxide.
* May be additionally required during highly stimulating parts of the surgical procedure.
¶ Assumes: IV induction with propofol 1 to 2 mg/kg, maintenance of TIVA with propofol 80 to 180 mcg/kg/minute (TCI 3 to 5 mcg/mL), and no N 2 O administration.
Δ We titrate the loading dose of fentanyl or sufentanil using the clinical endpoints during induction, such as either a decrease of respiratory rate or onset of sedation.
◊ Fentanyl infusion should be used with caution and adjusted accordingly due to its long, context-sensitive half-life.
References:
1. Erhan E, Ugur G, Gunusen I, et al. Propofol - not thiopental or etomidate - with remifentanil provides adequate intubating conditions in the absence of
neuromuscular blockade. Can J Anaesth 2003; 50:108.
2. Jellish WS, Leonetti JP, Avramov A, et al. Remifentanil-based anesthesia versus a propofol technique for otologic surgical procedures. Otolaryngol Head Neck
Surg 2000; 122:222.
3. Eberhart LH, Eberspaecher M, Wulf H, et al. Fast-track eligibility, costs and quality of recovery after intravenous anaesthesia with propofol-remifentanil versus
balanced anaesthesia with isoflurane-alfentanil. Eur J Anaesthesiol 2004; 21:107.
4. Philip BK, Kallar SK, Bogetz MS, et al. A multicenter comparison of maintenance and recovery with sevoflurane or isoflurane for adult ambulatory anesthesia. The
Sevoflurane Multicenter Ambulatory Group. Anesth Analg 1996; 83:314.
5. Wuesten R, Van Aken H, Glass PS, et al. Assessment of depth of anesthesia and postoperative respiratory recovery after remifentanil- versus alfentanil-based
total intravenous anesthesia in patients undergoing ear-nose-throat surgery. Anesthesiology 2001; 94:211.
6. Montes FR, Trillos JE, Rincón IE, et al. Comparison of total intravenous anesthesia and sevoflurane-fentanyl anesthesia for outpatient otorhinolaryngeal surgery. J
Clin Anesth 2002; 14:324.
7. Jellish WS, Leonetti JP, Buoy CM, et al. Facial nerve electromyographic monitoring to predict movement in patients titrated to a standard anesthetic depth.
Anesth Analg 2009; 109:551.
8. Vuyk J. Clinical interpretation of pharmacokinetic and pharmacodynamic propofol-opioid interactions. Acta Anaesth Belg 2001; 52:445.
9. Stanski DR, Shafer SL. Quantifying anesthetic drug interaction. Implications for drug dosing. Anesthesiology 1995; 83:1.
10. Twersky RS, Jamerson B, Warner DS, et al. Hemodynamics and emergence profile of remifentanil versus fentanyl prospectively compared in a large population of
surgical patients. J Clin Anesth 2001; 13:407.
11. Miller DR, Martineau RJ, O'Brien H, et al. Effects of alfentanil on the hemodynamic and catecholamine response to tracheal intubation. Anesth Analg 1993;
76:1040.
12. Thompson JP, Hall AP, Russell J, et al. Effect of remifentanil on the haemodynamic response to orotracheal intubation. Br J Anaesth 1998; 80:467.
13. McAtamney D, O'Hare R, Hughes D, et al. Evaluation of remifentanil for control of haemodynamic response to tracheal intubation. Anaesthesia 1998; 53:1223.
14. Jeon YT, Oh AY, Park SH, et al. Optimal remifentanil dose for lightwand intubation without muscle relaxants in healthy patients with thiopental coadministration:
a prospective randomised study. Eur J Anaesthesiol 2012; 29:520.
15. Demirkaya M, Kelsaka E, Sarihasan B, et al. The optimal dose of remifentanil for acceptable intubating conditions during propofol induction without
neuromuscular blockade. J Clin Anesth 2012; 24:392.
16. Stefanutto TB, Feiner J, Krombach J, et al. Hemoglobin desaturation after propofol/remifentanil-induced apnea: a study of the recovery of spontaneous
ventilation in healthy volunteers. Anesth Analg 2012; 114:980.
17. Gulhas N, Topal S, Erdogan Kayhan G, et al. Remifentanil without muscle relaxants for intubation in microlaryngoscopy: a double blind randomised clinical trial.
Eur Rev Med Pharmacol Sci 2013; 17:1967.
18. Mencke T, Jacobs RM, Machmueller S, et al. Intubating conditions and side effects of propofol, remifentanil and sevoflurane compared with propofol, remifentanil
and rocuronium: a randomised, prospective, clinical trial. BMC Anesthesiol 2014; 14:39.
19. Derrode N, Lebrun F, Levron JC, et al. Influence of peroperative opioid on postoperative pain after major abdominal surgery: sufentanil TCI versus remifentanil
TCI. A randomized, controlled study. Br J Anaesth 2003; 9:842.
20. De Baerdemaeker LE, Jacobs S, Pattyn P, et al. Influence of intraoperative opioid on postoperative pain and pulmonary function after laparoscopic gastric
banding: remifentanil TCI vs sufentanil TCI in morbid obesity. Br J Anaesth 2007; 99:404.
21. Bidgoli J, Delesalle S, De Hert SG, et al. A randomised trial comparing sufentanil versus remifentanil for laparoscopic gastroplasty in the morbidly obese patient.
Eur J Anaesthesiol 2011; 28:120.
22. Vuyk J. TCI: supplementation and drug interactions. Anaesthesia 1998; 53 Suppl 1:35.
23. Pérus O, Marsot A, Ramain E, et al. Performance of alfentanil target-controlled infusion in normal and morbidly obese female patients. Br J Anaesth 2012;
109:551.
The advantages of opioid-based anesthesia for head and neck surgery
Powerful intraoperative analgesia
Excellent postoperative pain control
Superior maintenance of controlled hypotension
Decreased general anesthetic requirements
Promotion of patient immobility
Improved hypnotic monitoring
Improved intraoperative neurophysiologic monitoring
Potent suppression of upper airway reflexes
Promotion of smooth and rapid emergence from anesthesia
DAS extubation guidelines: Basic algorithm
DAS: Difficult Airway Society; OSA: obstructive sleep apnea; HDU: high dependency unit; ICU: intensive care unit; O 2 : oxygen.
Reproduced from Popat M, Mitchell V, Dravid R, Patel A, Swampillai C, Higgs A. Difficult Airway Society Guidelines for the management of tracheal extubation.
Anaesthesia 2012; 67: 318-340, with permission from the Association of Anaesthetists of Great Britain & Ireland/Blackwell Publishing Ltd.
DAS extubation guidelines: "Low-risk" algorithm
The technique described for awake extubation is a suggested approach. Practice may vary in experienced hands.
DAS: Difficult Airway Society; O 2 : oxygen.
Reproduced from Popat M, Mitchell V, Dravid R, Patel A, Swampillai C, Higgs A. Difficult Airway Society Guidelines for the management of
tracheal extubation. Anaesthesia 2012; 67: 318-340, with permission from the Association of Anaesthetists of Great Britain & Ireland/Blackwell
Publishing Ltd.
DAS extubation guidelines: "At-risk" algorithm
DAS: Difficult Airway Society; HDU: high dependency unit; ICU: intensive care unit; O 2 : oxygen.
* Advanced techniques: Require training and experience.
Reproduced from Popat M, Mitchell V, Dravid R, Patel A, Swampillai C, Higgs A. Difficult Airway Society Guidelines for the management of tracheal extubation. Anaesthesia
2012; 67: 318-340, with permission from the Association of Anaesthetists of Great Britain & Ireland/Blackwell Publishing Ltd.

Anesthesia For Head and Neck Surgery - UpToDate

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Anesthesia For Head and Neck Surgery - UpToDate

Uploaded by

Copyright:

Available Formats

Anesthesia for head and neck surgery - UpToDate 07/09/20 19:58

Official reprint from UpToDate®

● (See "Airway management for induction of general anesthesia".)

Airway management issues specific to H&N procedures are discussed here.

● Maintenance of a stable plane of anesthesia during varying degrees of stimulation

Advantages of this technique include the following:

TCI technology is not available in the United States.

● Suppresses airway reflexes

JV can be performed with infraglottic, supraglottic, or transtracheal techniques.

● Need for reintubation

SUMMARY AND RECOMMENDATIONS

Use of UpToDate is subject to the Subscription and License Agreement.

Topic 94228 Version 13.0

Predictors of difficult videolaryngoscopy

Otolaryngologic and cardiac surgery

Sniffing head positioning

Decreased cervical spine motion

Restricted oropharyngeal space (edema, bleeding, retrognathia)

Prepared with data from:​

Graphic 108798 Version 4.0

Components of the preoperative airway physical examination

Airway examination component Nonreassuring findings

Length of upper incisors Relatively long

Interincisor distance Less than 3 cm

Shape of palate Highly arched or very narrow

Compliance of mandibular space Stiff, indurated, occupied by mass, or non-resilient

Thyromental distance Less than three ordinary finger-breadths

Length of neck Short

Thickness of neck Thick

Graphic 108981 Version 4.0

Predictors of difficult and impossible mask ventilation

Difficult mask ventilation Impossible mask ventilation

Mallampati grade 3 to 4 Mallampati grade 3 to 4

Graphic 109108 Version 3.0

Predictors of combined difficulty with mask ventilation and direct laryngoscopy

Predictors of difficult/impossible mask ventilation Modified and additional predictors

Mallampati grade 3 to 4 Age ≥46 years

​Courtesy of Dr. Vladimir Nekhendzy.

Graphic 109112 Version 4.0

Expert airway management

Surgery-specific airway management requirements

Versatility with difficult airway devices and techniques

Proficiency with different ventilation techniques and strategies

Provision of a stable plane of anesthesia and a clear surgical field

Moderate controlled hypotension

Immobility of the surgical field

Absence of patient movement

Avoidance of iatrogenic motion interference

Smooth and rapid emergence from anesthesia

SGA as the primary ventilatory device

Fast-tracking patients for discharge

Courtesy of Dr. Vladimir Nekhendzy.

Graphic 108795 Version 2.0

American Society of Anesthesiologists difficult airway algorithm

Graphic 94447 Version 8.0

Airway management considerations for head and neck surgery

Expert airway management

Airway management during induction of anesthesia

Airway management during extubation

Courtesy of Dr. Vladimir Nekhendzy.

Graphic 108797 Version 2.0

Stratification and doses of opioids for head and neck procedures

Prepared with data from:

Courtesy of Dr. Vladimir Nekhendzy.