Anaesthetic Concerns for Functional Endoscopic Sinus Surgery

REVIEW

Anaesthetic Concerns for Functional Endoscopic Sinus Surgery Pei Yu Tan, MBBS, MMed (Anaes), Ruban Poopalalingam, MBBS, MMed (Anaes) Department of Anaesthesiology, Singapore General Hospital, Singapore

ABSTRACT Functional endoscopic sinus surgery (FESS) is the primary approach used today for the surgical treatment of chronic sinusitis. The aim of our review is to look at the increasing body of literature highlighting the various anaesthetic techniques that can be employed in the optimisation of surgical conditions and safety of a surgical procedure with significant potential risk. Keywords: Airway, Anaesthesia, Haemostasis, Hypotension, Otorhinolaryngology, Propofol

INTRODUCTION Functional endoscopic sinus surgery is now a common surgical procedure in the otorhinolaryngology specialty. It is associated with a high rate of success (approximately 90%) for symptomatic improvement in patients with medically refractory chronic rhinosinusitis and chronic polypous rhinosinusitis1.

In current times the evolution of surgical technique has allowed surgeons to become much more aggressive with the extent of their resection. A general anaesthetic will then allow: • Immobile surgical field • Effective airway protection

Adverse events are rare, most of which relate to the close proximity of the paranasal sinuses to the orbits and brain. Major complications include dura puncture, cerebrospinal fluid leak, meningitis, orbital and optic nerve trauma and extensive haemorrhage2,3. As such the option for the procedure to be done under general anaesthesia offers numerous advantages and the role of the anaesthetist in these procedures is undoubtedly significant. LOCAL OR GENERAL ANAESTHESIA The classic FESS procedure was initially done under topical anaesthesia with sedation. In this manner, patients would be conscious and able to signal any kind of pain or discomfort, alerting and allowing the surgeon to minimise trauma and complications4,5.

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• Adequate analgesia • Patient comfort Currently, local anaesthesia is still considered suitable for minor procedures in selected patients, but general anaesthesia is preferred for most cases to meet more challenging surgical needs6. MINIMISING SURGICAL BLEEDING Haemorrhage decreases visibility of the surgical field during the FESS procedure and is directly related to risk of vascular, orbital and intracranial complications as well as procedural failure7,8. Hence it is of vital importance to the surgeon as well as anaesthetist to minimise surgical bleeding for this operation9.

Proceedings of Singapore Healthcare  Volume 23  Number 3  2014

Anaesthetic Concerns for Sinus Surgery

Bleeding may be difficult to control surgically due to the extensive vascular supply in the sinus region and pathophysiological changes in the patient. Capillary bleeding is the most serious problem of note in this procedure, barring any inadvertent trauma to the feeding arterial and venous vessels10. Fortunately, bleeding from the capillary circulation may be greatly reduced by decreasing the patient’s mean arterial pressure and by local vasoconstriction. Methods to decrease haemorrhage include: Positioning The reverse Trendelenburg 15° head up allows for venous decongestion of the upper part of the body by increasing venous pooling of blood in the lower extremities. Every 2.5 cm above the heart correlates to a decrease of 2 mm Hg in arterial blood pressure supply11,12. This has been shown to improve the endoscopic field of view13. Preoperative steroid administration This can be given in cases of severe nasal polyposis for its anti-inflammatory effects and decrease in mucosal oedema, improving visibility during the procedure14,15. Injected and topical local anaesthetics and vasoconstrictors These can help to relieve postoperative pain, decrease blood loss and mucosal congestion. Commonly used vasoconstrictors include cocaine, epinephrine, and phenylephrine16. Cocaine has local anaesthetic and vasoconstrictor properties. Systemic absorption of these agents may cause hypertension, tachycardia, and other arrhythmias; hence they should be used with great caution in patients with coronary heart disease, congestive heart failure, malignant arrhythmias, poorly controlled hypertension, and in those taking monoamine oxidase inhibitors17. It is recommended that the initial dose of phenylephrine should not exceed 0.5 mg in adults (4 drops of a 0.25% solution) or 20.0 μg/kg in children (up to 25 kg). If severe hypertension is present after administration of phenylephrine, antihypertensive agents that are direct vasodilators or α-antagonists are the appropriate therapy18. Hypotension induced by epinephrine under general anesthesia is seldom mentioned, but temporary

marked hypotension is proven to be induced in a predictable manner, lasting no longer than 4 minutes after local infiltration with epinephrinecontaining local anaesthetics19. Considering the potential for adverse side effects, the effect of topical application of epinephrine 1:100,000 has been studied and it may actually be able to provide a similar haemostatic effect as intranasal injection during FESS20. In a recent study, CohenKerem et al.21 compared the effectiveness of topical 1:1,000 epinephrine vs injected local anesthetic containing 1:100,000 epinephrine during FESS. In this study, it was reported that submucosal injection of local anaesthetic with epinephrine facilitated improved surgical condition; however, increased haemodynamic fluctuations were noted after infiltrations. Body temperature Maintenance of normothermia is vital for the function of platelets and coagulation factors essential in haemostasis22,23. Maintenance of anaesthesia depth Depth of anaesthesia is important in avoiding any coughing or straining by the patient during a light anaesthetic plane which will result in an increase in intrathoracic pressure and hence impair venous drainage from the head and increase surgical bleeding. The use of muscle relaxants will also effectively prevent such occurrences during the procedure. Intermittent positive pressure ventilation should be adjusted such that the airway pressures are kept to a minimum. Avoidance of the use of positive end expiratory pressure is also helpful via preventing higher intrathoracic pressure9,24. Choice of anaesthetic agent Volatile anaesthetic agents cause smooth muscle relaxation and decreases systemic vascular resistance. Tissue perfusion is increased due to vasodilation and may also contribute to surgical bleeding. Initial studies have suggested that the intraoperative blood loss was reduced with propofol total intravenous anaesthesia (TIVA) compared to volatile agents25–28. However, more recent studies do not show significant difference after excluding the effect of concomitant use of remifentanil29–31. The use of propofol has the advantage of not just reducing systolic blood pressure via a lesser decrease in systemic vascular resistance, but also


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able to quickly blunt the sympathetic response to endotracheal tube insertion and periods of surgical stimulation. Propofol also decreases cerebral metabolism and hence cerebral blood flow is reduced by autoregulation. This reduces flow via the ethmoidal and the supraorbital artery which supply the ethmoid, sphenoid and frontal sinuses; improving surgical visibility32. Two published narrative reviews have compared surgical field and blood loss during FESS. Amorocho et al.33 found propofol general anaesthesia improved the surgical field and reduced blood loss whereas Baker et al.34 concluded that propofol general anaesthesia improved the surgical field but did not reduce surgical blood loss. A recent Cochrane systemic review found that deliberate hypotension with propofol TIVA did not decrease total blood loss and only improved the quality of surgical field by less than one category on a scale of 0 (no bleeding) to 5 (severe bleeding), with no significant difference in operating times. Although it is of note that the only four studies with 278 participants were included in this review and randomised control trials with good quality methodology and large sample size are required to investigate the effectiveness of deliberate hypotension with propofol for FESS31. Remifentanil Opioids cause a drop in blood pressure during anaesthesia and minimises surges in blood pressure due to surgical pain. Remifentanil has the advantages of being a short acting but potent opioid that can be easily titrated to patient’s haemodynamic state35. This enables better control of blood pressure to achieve blood pressure targets for hypotensive anaesthesia even during sudden surges in surgical stimulation and pain without prolonged effects. Controlled hypotension Controlled hypotension refers to a deliberate lowering of the systemic blood pressure to 20 percent less than the patient’s baseline blood pressure. This decreases hydrostatic pressure within capillaries and hence decreased blood loss by capillary ooze. However there are limitations to controlled hypotension including reduced perfusion to vital organs such as the brain, heart and kidneys. Absolute contraindications to controlled hypotension include evidence of cerebrovascular

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insufficiency, coronary disease and decompensated heart failure36; relative contraindications will include other organ dysfunction (eg. renal, hepatic, pulmonary), severe anaemia and hypovolaemia. When used judiciously and when no contraindications are present, it has been found to be effective in providing better surgical field without postoperative complications due to intraoperative hypotension37. A study by Boezaart et al. showed that good operating conditions can be obtained with esmolol-induced hypotension even at mild hypotension with mean arterial pressure more than 65 mm Hg, which was postulated to be in part due to unopposed alpha-adrenergic effect on the mucous membrane vasculature by esmolol38. Choices of agents to maintain controlled hypotension will include glyceryl trinitrate, β-blockers39, α-agonists such as clonidine40, magnesium sulphate41 and remifentanil42. The agent used should ideally be short-acting and easily titratable and its effects should not last into the post-operative period. AIRWAY CHOICES An endotracheal tube (ETT) has a cuffed seal which sits below the vocal cords thereby helps to prevent aspiration and protect the airway and hence is known to be a definitive airway. The oral preformed south-pointing Ring-Adair-Elwyn ETT and armoured ETT have the advantage of a lesser tendency to kink versus a standard ETT and is usually positioned either in the midline and secured to the chin or taped at the angle of the mouth depending on surgeon’s preference and whether software guided surgical navigation systems such as BrainLab® is employed. In contrast the laryngeal mask airway (LMA) is a supraglottic device and thus is not traditionally believed to be able to provide airway protection. However, this may not be true as newer evidence have come to show. Blood and secretions can track along the outer surface of the ETT to the level of the vocal cords and subglottis. Direct comparisons of lower airway contamination by fibre optic examination at the end of nasal surgery have shown that patients on spontaneous ventilation via a flexible LMA have the same or even lower risk of having blood in the airway compared to patients on an ETT43–47. It is, however, reasonable to intubate patients with increased risk of aspiration such as



those with delayed gastric emptying and known gastro-oesophageal reflux. Insertion of the LMA after induction of anaesthesia also causes less sympathetic response than tracheal intubation as the larynx is not directly stimulated; hence allowing the further advantage of haemodynamic stability48. The LMA also offers added advantage during emergence compared to ETT as it is better tolerated and less stimulating to the airway and hence contributes to reduced bleeding in the immediate post-operative period. As the LMA can be removed in the recovery unit, it may also enable faster turnaround time in a full operating list. However, the switch in responsibility in post-operative airway management of the LMA to the recovery nurse will also mean that help must be immediately available if airway obstruction is encountered in the recovery area. The flexible LMA is preferred over the other LMA devices available due to its armored tubing which allows more flexibility and prevents kinking during taping, thereby avoiding physical obstruction to the surgeons. However care must be taken to ensure that the LMA sits well and is secured well as the airway is shared in FESS procedure with the surgeon and dislodgment of the LMA is not unknown or uncommon. It is also good practice to determine the seal pressure of the LMA. In addition LMA removal should only be performed when patients are fully awake and able to open the mouth on command. The laryngeal mask airway should not be deflated prior to removal so that secretions will not flow into the trachea.

Methods of ensuring smooth emergence include: Use of lignocaine Lignocaine can help reduce coughing and straining during extubation and may be administered for this purpose in a variety of methods including intravenously, as a local spray on the vocal cords and via the filling of the ETT cuff. Intravenous lignocaine in doses of 1.0–2.0 mg/kg has been shown to transiently suppress coughing and other airway reflexes4–9. However, the duration of intravenous lignocaine is short (5–20 min)50–52. The local effects of topical lignocaine sprays and lignocaine-filled ETT cuffs are believed to work on the rapidly adapting stretch receptors (RAR) in the tracheal mucosa, which are irritant receptors involved in the cough reflex53. A local lignocaine spray prior to extubation has been known to effectively suppress ETT-induced coughing54. This has been administered in a variety of methods including via simple administration from a syringe to the outer aperture of the ETT prior to extubation55, inserting a nozzle into the ETT and spraying56, and via proprietary modified ETTs such as laryngotracheal instillation of topical anaesthesia (LITA™)57 tubes with good results. Lignocaine diffuses across ETT cuffs, which enables the cuff to serve as a reservoir for local anaesthetic, However, the rate of lignocaine diffusion across ETT cuffs is slow and time has been shown to be an important factor in developing neural blockade58.

The use of a throat pack is strongly advocated as it will help to reduce blood contamination of the airway. At the end of the surgery the pack should be removed and a careful inspection and suctioning of the oral cavity and postnasal space should be performed to ensure no clots or oral packs are left behind which will lead to detrimental results49.

The use of sodium bicarbonate to alkalinise the lignocaine solution used to fill ETT cuffs is shown to improve speed of diffusion and has been shown to be efficacious. For a normal-sized adult, 10 ml of fluid is required to distend the ETT cuff to an acceptable pressure that prevents air leaks as well as avoid mucosal oedema. A variety of concoctions have been described, including 2 ml of lignocaine 2% (40 mg) and 8 ml of sodium bicarbonate 8.4%59–60.

SMOOTH EMERGENCE AND REVERSAL The obvious advantage of a smooth emergence will be that of the avoidance of straining and sympathetic release that will increase post-surgical bleeding, decrease the risk of sore throat and patient discomfort.

It is important to be aware of the possibility of local anaesthetic toxicity in view of the generous amount that is administered to the patient via packs and injections pre- and intra-operatively by the surgical team and hence good communication should exist between surgeons and anaesthetists.


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Another potential side effect of topical lignocaine administration to take note of will include the blunting of protective airway reflexes, which is of significance in view of possible airway bleeding; hence, there is a need for greater vigilance during extubation. Use of remifentanil Remifentanil is effective in controlling the haemodynamic response to surgery by the lowering of heart rate, cardiac output and blood pressure. In addition to this, it has the added advantage of rapid titratability and faster recovery due to the short half-life non-organ dependant elimination via nonspecific plasma esterases61,62. As the analgesic effect of remifentanil diminishes rapidly after the cessation of infusion, the effects of this will be felt immediately. Hence, there is a need to provide adequate analgesia via longer acting opioids, non steroidal antiinflammatory drugs and acetaminophen to prevent a rebound phenomenon when surgery is concluded. Recent studies looking into the effective effect-site concentration of remifentanil for preventing cough during emergence with target-controlled infusion have arrived at 2.94 ng/ml for men after nasal surgery63 and 2.14 ng/ml for women after thyroid surgery64. Deep versus awake extubation The advantage of awake extubation for FESS is the return of laryngeal reflexes that allow airway protection from further contamination with blood and secretions. The disadvantages include possibility of laryngospasm, coughing and bucking with subsequent oxygen desaturation, and increased risk of bleeding49. Deep extubation allows a smoother emergence from anaesthesia while allowing a faster turnover in the operating theatre. However there are distinct pitfalls including the risk of laryngospasm and obstruction as well as that of an unprotected airway in a patient at high risk of aspiration from blood in the airway. This may be avoided with additional suctioning with direct visualisation of the glottis, using a regular laryngoscope or even a video laryngoscope. The presence of nasal packs placed at the end of the procedure also presents a partial obstruction of the upper airways and will be a challenge in maintaining a patent airway based only on oropharyngeal flow. It is helpful to include this information during pre-operative counselling and to remind patients to breathe through their mouth when they awake. Nasal packs

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can also worsen symptoms of patients with known obstructive sleep apnea65. POST-OPERATIVE CARE Nausea and vomiting Nausea and vomiting are important post-operative complications in all surgical settings. The presence of blood in the stomach, inflammation of the uvula and throat, and the occasional use of opioids for pain control are all contributing factors. Decompression of the stomach with an orogastric tube should be performed prior to extubation. Prophylaxis with ondansetron and dexamethasone, should be strongly considered. Should the patient develop severe post-operative nausea and vomiting despite best efforts, rescue intravenous anti-emetics and hydration can be provided and in the worst case scenario, the patient may need to be admitted for further monitoring33,66. The use of TIVA with propofol has also been shown to result in a clinically relevant reduction of post-operative nausea and vomiting compared traditional volatile anesthesia67,68. Post-operative pain The expected postoperative pain from FESS may range from mild to moderate, and is due to surgical trauma as well as nasal packing. Pre-operative local anaesthetics are used, but are not adequate on their own to alleviate post-operative pain. No differences have been found between infiltration with longacting (bupivacaine) or short-acting (lignocaine) local anaesthetics69,70. Routine analgesic treatment is usually based on non-opioid analgesics with rescue opioids. Oral acetaminophen and an NSAID/ cyclo-oxygenase 2 inhibitor usually provide safe and effective analgesia33. CONCLUSIONS Functional endoscopic sinus surgery is a widely accepted and increasingly popular procedure that is acceptable to patients who have medically refractory rhino-sinusitis and enjoys a high success rate. For the anaesthetist, it provides an interesting challenge to use the latest drugs and techniques available in order to allow an optimal operating field while decreasing the risk of surgery and improve patient safety and satisfaction. Newer drugs such as remifentanil have proven their superiority in multiple trials in improving blood loss and surgical field with minimal side effects. In contrast, the current evidence comparing TIVA versus volatile agents do not show marked difference after excluding the beneficial effect of



remifentanil, hence we await results from more research before further conclusions can be drawn.

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