Difficulty: Intermediate to Advanced | Prerequisites: Parts 1 and 2 (Anatomy, Pharmacology, Techniques), basic understanding of paediatric anaesthesia principles.
This final set of notes covers procedure-specific anaesthesia for the major ENT and maxillofacial operations: middle-ear procedures, tonsillectomy and adenoidectomy (including bleeding tonsil), thyroid surgery, cleft palate and lip repair, dental restoration, sinus and nasal procedures, trauma (including Le Fort fractures), and radical neck dissection with laryngectomy. Each procedure brings its own blend of the core ENT challenges (shared airway, nerve preservation, bleeding, PONV, fire risk). The material here is high-yield for exams because questions often test your ability to match the right anaesthetic approach to a specific surgical scenario.
Middle-ear surgery demands awareness of N₂O effects on closed air spaces and facial-nerve monitoring. Tonsillectomy is common but the bleeding tonsil is a genuine emergency (assume full stomach plus hypovolaemia, resuscitate first, then rapid-sequence induction). Thyroid surgery requires euthyroid status preoperatively, nerve-integrity monitoring, and vigilance for postoperative hypocalcaemia and neck haematoma. Le Fort II and III fractures mean no nasal tubes. Radical neck dissection involves long operations with major blood loss, venous air embolism risk, and carotid sinus manipulation.
N₂O and the middle ear
N₂O is 34 times more soluble than nitrogen. It enters the middle-ear space faster than nitrogen can leave. If the eustachian tube is blocked (as in an anaesthetised patient who cannot yawn or swallow), middle-ear pressure rises. When N₂O is discontinued, the rapid reabsorption creates negative pressure that can displace a graft.
In simple terms, N₂O inflates the middle ear like a balloon during surgery, then deflates it suddenly when you turn it off, potentially popping a graft loose.
Post-tonsillectomy haemorrhage (PTH)
Bleeding after tonsillectomy, the most common emergency in paediatric airway surgery. Rates range from 0.5% to 7.5%. About 75% of bleeds occur within 6 hours. The patient has typically swallowed blood, so assume a full stomach and hypovolaemia.
Think of it as a surgical emergency where the child looks deceptively stable until the swallowed blood causes sudden vomiting, aspiration risk, and haemodynamic collapse.
Tonsil position
Lateral position with the head slightly down, used for recovery after tonsillectomy. Allows blood to drain out of the mouth rather than onto the vocal cords or into the stomach.
In simple terms, tip the patient on their side with the head a touch lower so blood drains out, not in.
Chvostek sign
Facial muscle contraction elicited by tapping over the facial nerve, anterior to the ear. A clinical sign of hypocalcaemia.
Think of it as a twitch test: tap the cheek near the ear and watch for involuntary facial twitching, which suggests low calcium.
Trousseau sign
Carpal spasm provoked by inflating a blood-pressure cuff above systolic pressure for several minutes. Another clinical sign of hypocalcaemia.
In simple terms, inflate the BP cuff on the arm and wait. If the hand cramps into a claw shape, calcium is dangerously low.
NIM tube (nerve integrity monitor ETT)
A Medtronic flexible silicone endotracheal tube with four stainless-steel electrodes that contact the vocal cords. Used for intraoperative recurrent laryngeal nerve EMG during thyroid surgery. Red wire pair monitors the right cord; blue monitors the left.
Think of it as an ETT with built-in sensors that let the surgeon know the moment the recurrent laryngeal nerve is at risk.
Le Fort fractures
A classification of maxillofacial fractures based on the level of separation from the cranial base. Le Fort I is horizontal across the maxilla (low risk for nasal intubation). Le Fort II involves the bridge of the nose through the medial and inferior orbit (cribriform plate risk). Le Fort III is total separation of the midface from the cranial base (highest cribriform plate risk). Nasal tubes are avoided in Le Fort II and III.
In simple terms, the higher the Le Fort number, the more of the face is detached from the skull, and the greater the risk that a nasal tube ends up inside the cranium.
Samter triad
Nasal polyps, asthma, and aspirin allergy occurring together. Common in patients presenting for sinus and nasal procedures.
Think of it as the classic triple combination that flags a reactive-airway patient who may also have NSAID sensitivity.
Intermaxillary fixation (IMF)
Wiring or banding the teeth of the upper and lower jaws together after mandibular or maxillary fracture repair. The patient cannot open their mouth until the wires are cut. Wire cutters or scissors must be kept at the bedside at all times.
In simple terms, the jaws are wired shut. If the patient vomits or the airway is compromised, you need cutters immediately.
The middle ear is an air-filled space between the tympanic membrane and the oval window, connected to the nasopharynx by the eustachian tube. Nearby structures include the temporal lobe, cerebellum, jugular bulb, and labyrinth. The ossicles (malleus, incus, stapes) sit within it, and the facial nerve traverses it.
Adults: tympanoplasty, stapedectomy, ossiculoplasty (for otosclerosis), mastoidectomy, cholesteatoma removal.
Children: tympanoplasty, mastoidectomy, myringotomy, grommet insertion, cochlear implant.
Nerve preservation (facial nerve)
N₂O effect on the middle ear
Bleeding control
PONV
Local plus sedation allows intraoperative hearing testing and less bleeding, but requires patient stillness. Most middle-ear procedures are outpatient, so rapid recovery, good analgesia, and no nausea are priorities.
EMLA cream (eutectic mixture of local anaesthetics: lidocaine plus prilocaine) eases injection pain.
LMA or ETT. ETT is better if extreme neck extension or rotation is required.
Nerve stimulator for facial-nerve EMG: avoid relaxants after intubation.
Aim for smooth recovery without coughing or straining to protect any prosthesis.
Head-up tilt 15 to 20 degrees, avoid venous obstruction, normocapnia, controlled hypotension (systolic 80 to 90 mmHg or 20% MAP reduction).
Head-up position raises the risk of venous air embolism.
Agents: inhalational anaesthesia, labetalol or esmolol, dexmedetomidine, remifentanil, magnesium sulphate.
N₂O is 34 times more soluble than nitrogen, so it enters the middle ear faster than nitrogen leaves, raising pressure when the eustachian tube is blocked.
During tympanoplasty the ear is open (no pressure buildup), but once a graft is placed, continued N₂O can displace it.
When N₂O is stopped, rapid reabsorption creates negative pressure, risking graft dislodgement, serous otitis, stapes disarticulation, and impaired hearing.
Best practice: avoid N₂O entirely in tympanoplasty, or stop it at least 15 minutes before closure. N₂O also increases PONV.
A short procedure in young, healthy children. Grommets equalise middle-ear pressure for chronic or recurrent serous otitis media.
N₂O concern is irrelevant here because the ear is vented by the tube.
Mask or IV induction with sevoflurane, O₂, and N₂O. Intubation only if airway difficulty is expected.
For bilateral cases, discontinue the inhalation agent during the second side for prompt emergence.
Real-time identification and functional assessment of vulnerable nerves, most often facial (VII), recurrent or inferior laryngeal (X), vagus (X), and spinal accessory (XI). Injury to these nerves causes significant morbidity (e.g. facial paresis, hoarseness, aspiration).
Relaxants are permitted only at induction and intubation, not during maintenance, because they suppress EMG signals.
Local anaesthetics are also contraindicated on or near the monitored nerve, as they suppress muscle action-potential amplitude.
The two drug classes to avoid during facial, recurrent laryngeal, vagal, or cranial motor-nerve monitoring: neuromuscular blocking agents and local anaesthetics.
A conventional balanced anaesthetic (opioid plus nitrous/oxygen plus volatile) suits EMG and EEG cases.
Adjuncts: remifentanil or sufentanil infusion for blood-pressure control and haemostasis, midazolam for amnesia, selective deep extubation to limit straining (straining leads to bleeding and potential reexploration).
BAER (brainstem auditory-evoked response): used for acoustic neuroma, facial-nerve decompression, cerebellopontine angle surgery. Sensitive to volatile agents and nitrous (affects amplitude and latency).
SSEP (cortical somatosensory-evoked potentials): spinal fusion, tumour, decompression. Sensitive to volatile agents and nitrous.
MEP (motor-evoked potentials): spine (anterior columns). Sensitive to volatile agents and relaxants.
EEG/BIS: all cases, carotid endarterectomy. Sensitive to volatile agents.
Neuromuscular junction monitoring: measures blockade depth. Sensitive to relaxants (that is the point).
EMG (spontaneous aclONM and evoked pcIONM): thyroid, parathyroid, parotid, neck dissection, skull base. Sensitive to both relaxants and local anaesthetics (avoid both).
Declining but still very common in children. Potential for significant airway challenges: obstruction, shared or suspended airway, intubation and extubation difficulty, pain, need for rapid awakening.
In adults, tonsillectomy may accompany UPPP (uvulopalatopharyngoplasty) for Pickwickian syndrome or obstructive sleep apnoea (typically obesity, redundant pharyngeal tissue, and comorbidities).
Sevoflurane plus O₂ plus N₂O by mask.
LMA or ETT are both acceptable (a 2010 review found no major disadvantage to LMA and some superiority for less coughing and gagging, with more spontaneous ventilation).
Cuffed tube for children over 8 to 10 years. Size the tube for a leak at 20 cm H₂O (reduces croup and oedema).
The Crowe-Davis gag is inserted after the airway is secured. Re-evaluate the tube after placement, as the gag can move or occlude it.
The table is often turned 45 to 90 degrees before incision.
Blunt reflex activity
Rapid return of protective reflexes
Good analgesia
Reduced bleeding
Minimal PONV
Intermediate relaxants are acceptable but often unnecessary. Modest opioid plus IV acetaminophen. Dexamethasone plus ondansetron for PONV. Deep extubation when prudent.
2013 Cochrane review: insufficient evidence that NSAIDs increase post-tonsillectomy bleeding. NSAIDs cause less nausea and vomiting than opioids.
About 4 mL/kg (5% of blood volume). UPPP blood loss is slightly higher. Transfuse based on loss, labs, and patient factors.
Topical 2% (max 3 mg/kg) applied to glottic and supraglottic areas prevents postextubation stridor and laryngospasm. This is as effective as IV lidocaine at 1 to 2 mg/kg.
Ensure reflexes have returned and the airway is clear before extubation.
Recover in the tonsil position (lateral, head slightly down) so blood drains out rather than onto the cords.
Adults after UPPP often prefer middle or high Fowler position.
Use gentle, brief suction only (vigorous suction triggers laryngospasm and bronchospasm).
Contraindicated for paediatric post-tonsillectomy pain because of the risk of metabolic conversion to dangerously high morphine levels (ultrarapid metabolisers).
PONV occurs in up to 70% of patients in the first 24 hours. Persistent vomiting, poor intake, and desaturation are the top reasons for unplanned overnight admission. Orogastric suction at the end of surgery may reduce PONV.
This is the most common emergency in paediatric airway surgery.
Rates: 0.5% to 7.5%. Most common in patients over 15 years, males, those with frequent infectious tonsillitis, and after electrocautery (hot) versus cold technique.
About 75% bleed within 6 hours; the remaining 25% within 24 hours (occasionally up to day 6). Most present with slow oozing rather than profuse bleeding.
The patient has swallowed blood. Assume a full stomach and hypovolaemia. Look for tachycardia, hypotension, agitation, nausea, and vomiting. Check haemoglobin, haematocrit, and coagulation.
Management sequence: restore intravascular volume and blood first, then perform rapid-sequence induction. Have a second suction ready. Perform careful laryngoscopy (do not dislodge clots). Awake intubation may be needed. Head-down positioning protects the airway. Decompress the stomach. Extubate only after protective reflexes have returned.
Butterfly-shaped, two lobes plus isthmus, anterolateral to the trachea below the larynx. Largest endocrine gland (about 20 g). Supplied by superior and inferior thyroid arteries (off the common carotid). Blood flow is roughly five times the gland weight.
The RLN and the external branch of the SLN lie close to the lobes and are at risk during surgery.
Thyrotoxicosis: excess thyroid hormone in the system from any cause.
Hyperthyroidism (the most common cause of thyrotoxicosis): excess hormone from a hyperactive gland.
Render the patient euthyroid before elective surgery. Excess hormone drives sympathetic hyperactivity. Thyroid storm is rare but possible.
Thyroid cancer is the most common endocrine malignancy. Over 90% are well-differentiated: papillary (70 to 80%, early stage, over 95% 10-year survival) or follicular (10%, later stage, 85% 10-year survival). Surgery is the principal treatment.
Ensure the patient is euthyroid. Assess end-organ effects and airway involvement (a large goiter or tumour can cause tracheomalacia and airway compromise).
Assess the airway supine. Obtain a chest x-ray and neck or chest CT if compromise is suspected. ECG if comorbidities are present.
Hyperthyroid patients have a higher incidence of myasthenia gravis and may show increased sensitivity to relaxants.
Continue antithyroid drugs and beta-blockade through the morning of surgery.
Thionamides (methimazole 10 to 40 mg preferred, or propylthiouracil 100 to 450 mg): decrease hormone synthesis. Continue to the morning of surgery.
Iodide (SSKI 1 to 3 drops three times daily, or Lugol solution 5 drops three times daily): added about 1 week preoperatively to decrease hormone release and gland vascularity.
Beta-blockers (propranolol, atenolol, metoprolol): adrenergic suppression. Continued perioperatively and withdrawn gradually afterwards.
General endotracheal anaesthesia is standard. Succinylcholine for intubation (short, self-degrading).
Avoid relaxation after intubation if nerve testing is planned (paralysis blocks RLN assessment).
NIM tube: Medtronic nerve integrity monitor ETT with four stainless-steel electrodes contacting the cords for RLN EMG. Red wire pair for the right cord, blue for the left. Both paralysis and laryngeal lidocaine block accurate readings.
Positioning: supine, head elevated 30 degrees, neck extended on a roll (Rose position). Arms tucked, ulnar nerves padded. Avoid hyperextension if atlantoaxial instability is present. Protect the eyes.
Monitor for rising core temperature and a hyperdynamic response. Treat true hypotension with a direct vasopressor (phenylephrine), not ephedrine.
Hypocalcaemia (hypoparathyroidism): parathyroids removed or devascularised. Symptoms appear 24 to 96 hours postoperatively: perioral numbness, tingling, paraesthesias, carpopedal spasm, tetany, laryngospasm, QT prolongation, seizures, arrest. Chvostek sign (facial tap triggers contraction) and Trousseau sign (carpal spasm with BP cuff). Monitor ionised calcium. Treat severe cases with IV calcium gluconate or chloride (10 mL of 10%), then an infusion at 1 to 2 mg/kg/hr.
Recurrent laryngeal nerve injury: up to about 14%. Unilateral injury moves the ipsilateral cord to the midline, causing hoarseness. Bilateral injury moves both cords to the midline, causing biphasic stridor, respiratory distress, and aphonia, requiring emergent reintubation or tracheotomy.
Neck haematoma: a true surgical emergency causing airway obstruction and potential asphyxiation. Signs: neck swelling, pain or pressure, dyspnoea, stridor. Management: emergent evacuation, then airway management.
Full complication list (Box 43.4): hypocalcaemia/hypoparathyroidism, RLN injury (unilateral or bilateral), neck haematoma, thyroid storm, superior laryngeal nerve injury, infection, pneumothorax, tracheomalacia.
One of the most common craniofacial anomalies (about 1 in 700 births). Facial bones form during weeks 5 to 9, palatal bones during weeks 6 to 11. The cleft represents a failure of fusion. Up to 30% of patients have other anomalies (Down syndrome, Pierre Robin sequence, Treacher Collins syndrome).
Lip repair with primary tip rhinoplasty at about 3 months. Posterior hard palate plus soft palate at about 5 to 8 months (before speech).
Rule of 10s: weight at least 10 lb, haemoglobin at least 10 g, white cell count below 10,000/mm³, age over 10 weeks.
The laryngoscope blade can slip into the cleft. Pack the cleft with gauze. Use an oral RAE tube or flexible connector secured midline on the lower lip, with a specialised mouth gag. Remove all IV air bubbles (many of these children have cardiac anomalies, creating an air-embolus risk via right-to-left shunts).
A tongue suture taped to the cheek can relieve soft-tissue obstruction. Keep the airway clear at all times (blood and secretions trigger laryngospasm).
Routine induction plus oral RAE or flexible connector, taped midline on the lower lip. The surgeon may place a Logan bow across the upper lip, which can impair or prevent mask ventilation.
Extubate only when fully awake with intact reflexes. Protect the surgical site from the child's hands (mittens, armboards).
Indications: multiple cavities, cerebral palsy, Down syndrome, and uncooperative patients unsuitable for office local anaesthesia.
Population: often developmentally delayed. Common findings: small oropharynx, enlarged tonsils, large tongue, increased secretions, atlantoaxial instability, congenital heart disease. Phenytoin causes gingival hyperplasia (vascular tissue prone to bleeding).
Premedication: midazolam 0.5 mg/kg by mouth or ketamine 3 to 4 mg/kg intramuscularly.
Airway: nasal intubation usually facilitates dental work. Apply topical vasoconstrictor spray preoperatively. Dilate the nares with progressively larger lubricated nasal trumpets, then pass a lubricated ETT (blindly or via Magill forceps). Place the tube on the side opposite the surgeon. The surgeon may sew the tube to the nasal septum. Use throat packs to prevent gastric blood, and ensure removal before extubation.
Indications and population: chronic sinusitis drainage, polyp removal, deviated-septum repair, closed fracture reduction. Patients are usually young and healthy but many have allergies or reactive airways.
Samter triad: nasal polyps plus asthma plus aspirin allergy.
Vasoconstriction is essential due to the highly vascular mucosa. Options include epinephrine or cocaine (cocaine and phenylephrine are similar for septoplasty). A hypotensive technique or slight head elevation (10 to 20 degrees) also helps.
Bleeding: general anaesthesia with volatile agents (which cause vasodilation) produces more blood loss. Propofol and IV maintenance produce less. Remove the oropharyngeal pack, suction the stomach, and extubate awake with reflexes intact. IV or topical lidocaine reduces coughing and postoperative bleeding.
Airway obstruction mechanisms: oedema, oral-mucosa and palate bleeding, intraoral fractures, distorted nasal passages, pharyngeal or sinus injury, lacerations, and foreign bodies (avulsed teeth, clots, bony fragments).
Airway alternatives: fibreoptic laryngoscopy, retrograde wire, jet ventilation via cricothyrotomy, emergent tracheostomy.
Cervical spine: image all seven vertebrae. C7 is the most common fracture site. Suspect vertebral artery injury. Keep the head fixed with manual inline stabilisation or a rigid collar (remove the front to intubate). Treat as a full stomach.
Blunt anterior-neck or inhalation injury: blunt trauma can cause rapid airway occlusion from soft-tissue oedema or haematoma. Smoke inhalation or oral/nares blistering warrants immediate intubation (glottic oedema may not appear for hours).
Le Fort I: horizontal across the maxilla (floor of nose, hard palate, septum, pterygoid plates). Little airway difficulty; oral or nasal intubation is fine.
Le Fort II: triangular, through the bridge of the nose, medial and inferior orbit, beneath the zygoma. Cribriform plate disruption means a nasal tube risks intracranial placement.
Le Fort III: total separation of the midface from the cranial base (nasal root, ethmoid, orbits). Same cribriform risk: avoid nasal tubes.
Cerebrospinal fluid in the nose, blood behind the tympanic membrane, periorbital oedema, and raccoon-eyes haematoma all suggest a basal-skull fracture. A nasal tube could enter the cranium, causing meningitis or brain damage.
Investigate cervical-spine injury, subdural haematoma, pneumothorax, and intraabdominal bleeding. If the airway is in doubt in the emergency department, proceed with tracheostomy under local anaesthesia or awake oral intubation with topical anaesthesia.
Mandibular and maxillary fractures may be treated by wiring or banding the teeth together. Nasal intubation is usually best. Keep wire cutters or scissors at the bedside at all times. Extubate awake with intact reflexes. Type and crossmatch blood (blood loss can be extensive).
Sagittal mandible split or Le Fort osteotomy to correct anomalies. Nasal tube preferred (secure it without causing nares necrosis). Deliberate hypotension is common if the patient is stable. Extensive oedema over the first 24 hours may require the patient to stay intubated for several days. Extubate only when awake with reflexes intact.
Cancer invading neck musculature and structures, often with friable, bleeding tumours. Cumulative risk factors: smoking, alcohol, bronchitis, emphysema, cardiovascular disease. The tumour may interfere with eating, causing weight loss, malnutrition, anaemia, dehydration, and electrolyte imbalance. Prior radiation makes tissue stiff and intubation more difficult. Many patients are older with significant comorbidities.
Consult the surgeon about tumour nature, extent, location, prior therapy, imaging, and labs. Failed intubation attempts can cause haemorrhage and oedema, worsening airway compromise.
Pedicle or myocutaneous flaps (pectoralis major, trapezius, forehead) and microvascular free flaps. Small bowel can rebuild the oropharynx or oesophagus.
Determine the donor site to plan line placement. Avoid the internal jugular vein (near the surgical site): use subclavian or femoral for central access. Arterial line plus Foley catheter if hypotension is used.
A nerve stimulator is often used to locate distorted nerves, so avoid maintenance paralysis. Discuss preoperatively.
Two large-bore IVs (14 to 16 gauge). Type and crossmatch. Replace blood without fluid overload (positive balance leads to flap oedema, congestion, and vascular compromise). Colloids limit crystalloid volume. Maintain cerebral perfusion.
Surgical manipulation near the carotid sinus triggers a vagal reflex causing bradycardia, hypotension, and potentially arrest. Block with local anaesthetic near the sinus or give an anticholinergic.
Head-up positioning plus open neck veins creates risk. Monitor with precordial Doppler or transoesophageal echo. Aspirate air through the central line. Venous thrombus is also common (long surgery plus interrupted venous flow).
Oxygenate well before the trachea is transected. Withdraw the ETT to above the incision. Once the tracheostomy or reinforced tube is placed and ventilation is confirmed (bilateral breath sounds, chest excursion, end-tidal CO₂, inspiratory pressure), fully remove the ETT and suture the new tube to the chest wall. Switch to a tracheostomy cannula at the end.
Tracheostomy care, controlled ventilation, chest x-ray (rule out pneumothorax, haemothorax, pulmonary oedema). Monitor for laryngeal oedema from thrombosis. ICU overnight for major fluid and electrolyte shifts, altered ventilation-perfusion, and recovery from prolonged anaesthesia.
Total: removes the hyoid, entire larynx (epiglottis, false and true cords), cricoid, and 2 to 3 tracheal rings. The patient loses their voice and breathes through a tracheostomy. Swallowing remains intact.
Supraglottic (horizontal): removes the hyoid, epiglottis, and false cords. Normal voice and normal airway, but the patient may aspirate (especially liquids).
Vertical (hemi-): removes one true cord, false cord, arytenoid, and half of the thyroid cartilage. Hoarse but serviceable voice; normal airway and swallowing.
Laryngofissure/partial: removes one vocal cord. Hoarse but serviceable voice, sometimes near-normal.
Endoscopic (early carcinoma): removes part of one vocal cord. May have a normal voice with no other problems.
"N₂O is always contraindicated in ear surgery." It is irrelevant in myringotomy (the ear is vented by the tube), but should be avoided in tympanoplasty where a graft is placed in a closed space.
"A bleeding tonsil patient just needs to go straight to theatre." Resuscitate first. These patients have swallowed blood (full stomach) and are often hypovolaemic. Restore intravascular volume and blood before rapid-sequence induction.
"Unilateral RLN injury causes airway obstruction." Unilateral injury typically causes hoarseness only (ipsilateral cord goes to the midline). It is bilateral injury that moves both cords to the midline, causing stridor, respiratory distress, and potential complete obstruction.
"Any nasal tube is fine after facial trauma." In Le Fort II and III fractures, the cribriform plate may be disrupted. A nasal tube risks intracranial placement. Always check for CSF rhinorrhoea, raccoon eyes, and periorbital oedema before deciding on a nasal tube.
Post-tonsillectomy haemorrhage is one of the scenarios where the stakes of getting the sequence wrong are highest: attempting rapid-sequence induction in a hypovolaemic child who has not been resuscitated can cause cardiovascular collapse. The management of intermaxillary fixation (keeping wire cutters at the bedside) is a practical patient-safety measure that applies every time a jaw is wired shut, whether in a hospital ward or during transport. The carotid-sinus reflex during radical neck dissection is a real intraoperative event that can cause sudden arrest if not anticipated.
⚠️ N₂O in tympanoplasty: avoid entirely, or stop at least 15 minutes before graft closure. N₂O inflates the middle ear (pressure rise), then rapid reabsorption creates negative pressure that can displace the graft.
⚠️ Bleeding tonsil: assume full stomach plus hypovolaemia. Resuscitate first, then rapid-sequence induction. Have a second suction ready.
⚠️ Codeine is contraindicated for paediatric post-tonsillectomy pain (risk of ultrarapid metabolism to toxic morphine levels).
⚠️ Recover tonsillectomy patients in the tonsil position (lateral, head slightly down).
⚠️ Thyroid postoperative complications: hypocalcaemia (Chvostek sign, Trousseau sign), RLN injury (unilateral = hoarseness; bilateral = stridor and airway emergency), and neck haematoma (surgical emergency).
⚠️ Treat true hypotension in thyroid surgery with phenylephrine (direct vasopressor), not ephedrine.
⚠️ Neuromonitoring rule: no maintenance relaxants and no local anaesthetics on the monitored nerve.
⚠️ Le Fort II and III: avoid nasal tubes (cribriform plate risk). C7 is the most common cervical fracture site.
⚠️ Intermaxillary fixation: keep wire cutters or scissors at the bedside at all times.
⚠️ Radical neck dissection: avoid the internal jugular for central access (near the surgical site). Watch for venous air embolism (head-up plus open neck veins).
⚠️ Rule of 10s for cleft repair: weight at least 10 lb, haemoglobin at least 10 g, WCC below 10,000, age over 10 weeks.
True or false: N₂O should be avoided during myringotomy with tube placement.
Fill in the blank: In a bleeding tonsil, the first priority is to restore __________ before proceeding to rapid-sequence induction.
True or false: Unilateral recurrent laryngeal nerve injury causes complete airway obstruction.
Fill in the blank: The two clinical signs of hypocalcaemia after thyroid surgery are the __________ sign and the __________ sign.
True or false: Nasal intubation is safe in Le Fort III fractures.
Answers: 1. False (the ear is vented by the tube, so N₂O is irrelevant). 2. Intravascular volume and blood. 3. False (unilateral injury causes hoarseness; bilateral injury causes stridor and obstruction). 4. Chvostek, Trousseau. 5. False (cribriform plate disruption risks intracranial placement).
Q: Why is N₂O avoided during tympanoplasty but not during myringotomy?
A: In tympanoplasty, a graft seals the middle-ear space. N₂O enters faster than nitrogen leaves, raising pressure that can displace the graft. After discontinuation, rapid reabsorption creates negative pressure with the same risk. In myringotomy, the tube vents the ear, so pressure cannot build up.
Q: A child presents 4 hours after tonsillectomy with tachycardia, agitation, and repeated swallowing. What do you assume and what is the management sequence?
A: Assume post-tonsillectomy haemorrhage with a full stomach (swallowed blood) and hypovolaemia. Restore intravascular volume and blood first, then perform rapid-sequence induction. Have a second suction ready, perform careful laryngoscopy without dislodging clots, position head-down to protect the airway, decompress the stomach, and extubate only after protective reflexes have returned.
Q: Name three postoperative complications of thyroid surgery and the key clinical sign for each.
A: Hypocalcaemia (Chvostek sign: facial twitch on tapping; Trousseau sign: carpal spasm with BP cuff). Recurrent laryngeal nerve injury (hoarseness if unilateral; stridor and aphonia if bilateral). Neck haematoma (neck swelling, dyspnoea, stridor).
Q: What is the Samter triad, and why does it matter for anaesthesia in sinus surgery?
A: Nasal polyps, asthma, and aspirin allergy. It flags a patient with reactive airways who may be sensitive to NSAIDs, influencing both the anaesthetic plan and postoperative analgesia choices.
Q: During radical neck dissection, why is the internal jugular vein avoided for central venous access?
A: It lies near the surgical site and may be ligated or resected during the dissection. Use subclavian or femoral access instead.
Q: What two drug classes must be avoided during intraoperative facial or recurrent laryngeal nerve EMG monitoring, and why?
A: Neuromuscular blocking agents and local anaesthetics. Both increase latency, decrease amplitude, and raise the stimulus threshold, making it impossible to reliably detect nerve function.
Post-tonsillectomy haemorrhage management connects to paediatric resuscitation and the principles of rapid-sequence induction covered in emergency anaesthesia.
Thyroid storm and thyrotoxicosis link to the endocrinology and critical-care sections of any medical curriculum.
Le Fort fracture classification and cervical-spine management connect to trauma surgery and emergency medicine.
Neuromonitoring principles apply beyond ENT to spinal surgery, neurosurgery, and any case where nerve integrity is at risk.
middle-ear surgery, tympanoplasty, myringotomy, N₂O middle ear, nitrous oxide graft displacement, facial nerve monitoring, neuromonitoring, EMG, NIM tube, tonsillectomy, adenoidectomy, bleeding tonsil, post-tonsillectomy haemorrhage, PTH, tonsil position, codeine contraindicated paediatric, PONV, thyroid surgery, thyrotoxicosis, hyperthyroidism, euthyroid, thionamides, methimazole, recurrent laryngeal nerve injury, hypocalcaemia, Chvostek sign, Trousseau sign, neck haematoma, cleft palate, cleft lip, rule of 10s, Pierre Robin, dental restoration, nasal intubation, Samter triad, sinus surgery, Le Fort fracture, cribriform plate, intermaxillary fixation, wire cutters, radical neck dissection, laryngectomy, carotid sinus reflex, venous air embolism, tracheostomy hand-off, Chapter 43, ENT anaesthesia, maxillofacial surgery