Office-Based Laryngeal Surgery by Abdul-latif Hamdan & Robert Thayer Sataloff & Mary J. Hawkshaw

Author:Abdul-latif Hamdan & Robert Thayer Sataloff & Mary J. Hawkshaw
Language: eng
Format: epub
ISBN: 9783030919368
Publisher: Springer International Publishing

Fig. 6.5Two cc of 2% lidocaine topical anesthesia administered using a nebulizer

Fig. 6.6Topical anesthesia administered via a 25-gauge needle inserted through the cricothyroid membrane (a) showing the tip of the needle penetrating the airway, (b) showing the injection of the lidocaine into the airway

There is no clear consensus in the literature on the best anesthetic approach/technique for unsedated office-based laryngeal surgery. The choice of approach/technique is left to the discretion of the surgeon who needs to take into consideration patient related-factors such as anatomy and tolerance, as well as comorbidities. Patients with hyperactive gag reflex, abnormal oropharyngeal anatomy such as hypertrophic tonsils or prominent cervical osteophytes may not be eligible for peroral administration of topical anesthesia. Moreover, for some such patients, unsedated office-based surgery might not be the best approach. If there are compelling reasons to use office-based surgery, mild sedation may help overcome some of these problems, especially the hyperactive gag response. Often diazepam 5–10 mg the night before and 1 h before the procedure will be sufficient. Similarly, patients with obscure cervical landmarks may not be the ideal candidates for transcervical delivery of local anesthetic. Naunheim and Woo investigated the difference in patient satisfaction using three anesthetic techniques [23]. One hundred patients had topical anesthetic (lidocaine) delivered to the upper airway via either a nebulizer (n = 32), a cannula (n = 35), or a tracheal puncture (n = 33). Among the 90 patients who had surgery and had completed the survey, the highest satisfaction score was achieved in the tracheal puncture group, followed by the cannula group and the nebulizer group. Patients who received trans-tracheal topical anesthesia had the least amount of pain and nausea. Moreover, patient satisfaction correlated with the surgeons’ satisfaction, which also was higher in the tracheal group in comparison to the other groups. In a recent study of 154 patients who underwent 176 different office-based laryngeal procedures, Hamdan et al. reported no significant difference in anesthesia discomfort between those who underwent the transnasal, peroral fiberoptic, and trans-tracheal approaches (2.16 ± 1.39 vs. 2.4 ± 1.29 vs 2.21 + 1.13, respectively, p-value (0.825)). Similarly, there was no significant difference in the anesthesia time between the three groups [24].

In summary, the success in achieving topical anesthesia to the upper airway is determined in part by the patient’s readiness for the office-based laryngeal procedure. The absence of a gag reflex, decreased sensation in the laryngeal mucosa, and attenuated adductor reflex, are invariably reassuring signs that the larynx and pharynx are well anesthetized. Economy of time is paramount during surgery as the time window for full anesthesia effect from lidocaine rarely exceeds 15–20 min. Administration of local anesthesia a second time may be needed in selected cases. Alternatively, a longer acting agent such as Cetacaine may be used.

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