26.1 Nasal & Sinus Surgery, Nasotracheal Intubation & Craniofacial Procedures

Why This Topic Matters on the NCE

Domain IV.A.3.a of the content outline lists extracranial head procedures as six sub-topics, including nasal and craniofacial. Every one of these is a shared airway in a bleeding field, and the exam consistently tests the vasoconstrictor pharmacology, the airway plan, and the emergence.

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1. Functional Endoscopic Sinus Surgery

The vasoconstrictor problem

A bloodless field is essential for endoscopic visualization, so the surgeon applies topical and injected vasoconstrictors to the nasal mucosa, one of the most vascular surfaces in the body.

The phenylephrine rule is a high-yield exam item. If severe hypertension follows topical phenylephrine, treat with a direct vasodilator or an alpha-blocker — never with a beta-blocker alone. Beta-blockade in the setting of pure alpha-agonist-induced hypertension removes inotropic support against a massively increased afterload and precipitates pulmonary edema and cardiac arrest. The same unopposed-alpha logic applies after cocaine.

Airway and field management

• Oral RAE tube taped midline or to the lower lip, keeping the field clear.
• A throat pack prevents blood accumulating in the stomach and reducing postoperative nausea; it must be on the count and its removal explicitly verified.
• Reverse Trendelenburg of 10 to 15 degrees reduces venous congestion and improves the surgical field measurably.
• Total intravenous anesthesia with propofol and remifentanil produces a better surgical field than volatile anesthesia in comparative studies, largely through lower blood pressure and heart rate with preserved vascular tone.
• Controlled hypotension may be requested; balance field quality against organ perfusion and never permit it in patients with cerebrovascular or coronary disease.

The complications that matter

• Orbital penetration. The lamina papyracea separating the ethmoid sinus from the orbit is paper thin. Consequences range from periorbital ecchymosis to retrobulbar hematoma and blindness. Do not cover the eyes with opaque tape or drapes — the surgeon must be able to see and palpate the globe for sudden proptosis, and a common practical convention is that the eyes remain visible throughout.
• Skull base penetration with CSF leak, and rarely intracranial injury.
• Internal carotid artery injury where the artery is dehiscent in the sphenoid sinus — catastrophic and rare.

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2. Septoplasty, Rhinoplasty and Nasal Fracture

The same shared-airway and vasoconstrictor considerations apply, plus:

• Emergence is the critical phase. Coughing, bucking, and hypertension cause bleeding into the freshly operated nose and, in rhinoplasty, septal hematoma. Plan a smooth emergence with deep extubation where appropriate, remifentanil, or intravenous lidocaine.
• Suction the pharynx thoroughly before emergence; swallowed blood is a potent emetic.
• Postoperative nasal packing makes the patient an obligate mouth breather.

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3. Postoperative Bleeding After Nasal or Sinus Surgery

Returning to theatre for epistaxis or post-tonsillectomy bleeding is one of the most dangerous anesthetics in the entire specialty, and the reasoning is identical for both:

1. The stomach is full of swallowed blood — a rapid sequence induction with suction ready is mandatory.
2. The patient is hypovolemic, often much more than the visible blood suggests, because most of the loss has been swallowed. Resuscitate before induction; a hypovolemic patient given a standard induction dose will arrest.
3. The airway view will be worse than the first time from blood, clot, and edema. Have two working suctions, a range of tube sizes and stylets, and a surgeon present.
4. Cross-match blood and correct coagulopathy.

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4. Nasotracheal Intubation

Indicated when the mouth must be free — intraoral, dental, and oral-maxillofacial surgery.

Technique

• Prepare the nose with a topical vasoconstrictor and topical local anesthetic.
• Choose the more patent nostril; the right is conventionally used first because the standard tube bevel then faces the septum.
• Warm and soften the tube, and use a tube one size smaller than the oral equivalent.
• Advance perpendicular to the face along the floor of the nose, not cephalad toward the cribriform plate.
• Magill forceps direct the tube tip into the glottis, grasping the tube proximal to the cuff so the cuff is not punctured.

Contraindications and hazards

• Basilar skull fracture and midface (Le Fort II or III) fracture — absolute. Blind passage risks intracranial placement through the fractured cribriform plate. Signs of basilar skull fracture are raccoon eyes, Battle sign, CSF rhinorrhea or otorrhea, and hemotympanum.
• Coagulopathy and therapeutic anticoagulation — epistaxis.
• Nasal polyps, severe septal deviation, and prior transsphenoidal surgery.
• Bacteremia is common after nasal intubation.
• Turbinate avulsion and retropharyngeal dissection.

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5. Craniofacial Surgery

Cleft lip and palate

• Repair timing follows the "rule of tens" convention — roughly 10 weeks of age, 10 pounds, hemoglobin 10 g/dL for the lip; palate repair later.
• Associated syndromes are the real risk: Pierre Robin sequence (micrognathia, glossoptosis, cleft palate), Treacher Collins, Goldenhar. Anticipate a difficult airway, and remember that in Pierre Robin the airway typically becomes easier with age while Treacher Collins does not.
• An oral RAE tube is taped midline to the chin. The Dingman mouth gag can kink, compress, or dislodge the tube — reconfirm breath sounds and capnography after the gag is opened.
• Postoperative airway obstruction from a newly narrowed nasopharynx and tongue swelling; a tongue traction suture is often placed for postoperative airway rescue.
• Arm restraints prevent the child disrupting the repair.

Le Fort osteotomy and orthognathic surgery

• Nasotracheal or submental intubation is required to free the occlusion for intraoperative jaw relationship checks.
• Substantial and often underestimated blood loss in a long procedure; consider tranexamic acid.
• The jaw is wired or elastic-fixed at the end. Wire cutters or scissors must accompany the patient to recovery and remain at the bedside, and staff must know to cut in an emergency.
• Airway edema after prolonged surgery: assess with a cuff leak, consider delayed extubation.
• Le Fort fracture classification is directly testable: Le Fort I is a transverse maxillary fracture, Le Fort II is pyramidal involving the nasal bridge, and Le Fort III is craniofacial dysjunction. Le Fort II and III cross the cribriform plate, so nasal instrumentation is contraindicated.

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Exam Traps

• Do not give a beta-blocker alone for phenylephrine- or cocaine-induced hypertension — unopposed alpha causes pulmonary edema.
• Do not cover the eyes opaquely during endoscopic sinus surgery.
• Post-tonsillectomy and post-nasal bleeding means full stomach plus hypovolemia plus a worse airway.
• Le Fort II and III fractures and basilar skull fracture forbid nasal instrumentation.
• Wire cutters go to recovery with every wired jaw.