Nasal surgery is a common type of reconstructive and cosmetic surgery.1 While nasal surgery can be used alleviate difficult breathing due to a health condition, it can also serve to correct external nasal deformities for medical or aesthetic reasons.2 As nasal surgeries vary in purpose and invasiveness, anesthesia may look different from one surgery to the next. Thus, anesthesia providers must be familiar with the types and uses of nasal surgery, their role in the process and recent research on best practices.
Nasal surgery is medically indicated when a patient has nasal obstruction due to anatomic and functional problems.3 Objects that obstruct the nasal passages include thin pieces of bone, mucous membranes, nasal polyps, swollen or damaged tissue and tumors or growths.4 Nasal obstruction can contribute to sleep apnea and snoring, and may cause symptoms such as runny nose, recurrent sinus infections, reduced sense of smell, facial pain or headaches.4 Usually, options such as nasal irrigation, steroids and antihistamine sprays, oral medication, allergist evaluation and external nasal strips are the first steps for someone with dysfunctional airflow through the nasal passages.3 When such treatments are not successful in fixing the issue, surgery can improve the airway.3 Types of nasal surgeries include turbinate reduction, which helps alleviate swelling in turbinates (small nasal structures for cleansing and humidifying air); septoplasty, which is the surgical correction of defects in the nasal septum; and rhinoseptoplasty, which entails correction of the internal and external parts of the nose.2 Meanwhile, rhinoplasty is the cosmetic restructuring of the outside of the nose through changes in bone and cartilage.2 Nasal surgery can be conducted using an endoscope with or without image guidance, or by entering the sinus cavity through the upper jaw.4 The wide array of nasal surgeries calls for versatile anesthetic techniques.
Anesthesia providers play important roles in keeping their patients comfortable before, during and after nasal surgery. Before surgery, the anesthesiology practitioner must consult the patient about smoking history, general medical history and preoperative instructions such as discontinuing medication or fasting.5 During the procedure, the anesthesia provider will use a local or general anesthetic depending on the patient’s and surgeon’s preferences, type of surgery and any contraindications.4 Caution with airway control is especially crucial in nasal surgery, in which manipulation of the upper airway will cause bleeding.6 While many nasal surgeries are minimally invasive and allow patients to make quick recoveries, anesthesia providers might prescribe saline rinses, steroids, antibiotics and even narcotics to help their patients throughout the postoperative period.4 Because of elevated risk of bleeding, anesthesia providers may advise their patients to avoid aspirin and nonsteroidal anti-inflammatory drugs (NSAIDs) for up to two weeks.7 The anesthesiologist must take precautions to help patients throughout the entire perioperative period for nasal surgery.
Research shows that anesthesiology for nasal surgery can be complex. For one, the anesthesia provider must balance airway-related intraoperative and postoperative risks.6 According to Webster et al., awake extubation after intranasal surgery is the best way to protect the airway from aspiration of blood.6 However, awake extubation is usually accompanied by excessive coughing, which could increase the risk of postoperative bleeding.6 The authors’ study found that a flexible reinforced laryngeal mask airway provided a safe, protected airway with smoother emergence than tracheal intubation, thus avoiding complications during and after surgery.6 While Kaplan et al. found that the laryngeal mask airway was effective in protecting the upper airway from blood aspiration in nasal surgery, they also found a higher incidence of distal tracheal blood contamination.8 Meanwhile, Kim et al. showed that the risk of emergence agitation in adults undergoing general anesthesia for nasal surgery was increased fivefold by the presence of a tracheal tube.9 Emergence agitation can lead to severe consequences, including injury to self or others, removal of catheters, hemorrhage and self-extubation.9 This study also found that use of sevoflurane anesthesia increased likelihood of emergence agitation, suggesting that the type of anesthetic drug used is important in nasal surgery.9 Indeed, Kazak et al. found that nasal surgery patients who were premedicated with 600 milligrams of gabapentin needed less remifentanil and propofol, had lower intraoperative and postoperative pain scores, showed less anxiety and consumed less of a NSAID after the procedure.10 Karaaslan et al. found that in adult patients undergoing septoplasty or endoscopic sinus surgery, dexmedetomidine or midazolam combined with patient-controlled tramadol provided adequate analgesia and sedation.11 Patients who used dexmedetomidine used significantly less tramadol than did patients who used midazolam, suggesting that dexmedetomidine may have better analgesic effects.11 Additionally, Demiraran et al. found that postoperative local administration of levobupivacaine was more analgesic and longer lasting than a lidocaine-epinephrine combination.12 Because older studies show cardiac risk associated with topical application of cocaine for nasal surgery,13,14 more recent medical professionals have moved away from using cocaine in such surgeries.15 Evidently, many other anesthetic drugs and techniques can be appropriate for nasal surgery.
Nasal surgery is used to correct medical and cosmetic issues, and it has many forms and associated surgical techniques. Anesthesia providers focus primarily on airway control and management of bleeding during nasal surgery, for which they can use alternative ventilation mechanisms such as the laryngeal mask airway. Many anesthetic drugs may be useful for anesthesia and analgesia during and after nasal surgery; specific combinations of drugs may be up to the anesthesiology professional’s discretion. Future research should aim to optimize anesthetic technique for the various kinds of nasal surgery.
1. Stanford Health Care. Conditions Treated. 2019; https://stanfordhealthcare.org/medical-treatments/n/nasal-surgery/conditions-treated.html.
2. Stanford Health Care. Types of Nasal Surgery. 2019; https://stanfordhealthcare.org/medical-treatments/n/nasal-surgery/types.html#about.
3. Stanford Medicine. Nasal Surgery. Stanford Sleep Surgery 2020; https://med.stanford.edu/ohns/healthcare/sleepsurgery/treatments/nasal_surgery.html.
4. Rowden A. Everything you need to know about sinus surgery. Medical News Today. Brighton, UK: Healthline Media; April 16, 2017.
5. Shah RK. Deviated Septum Surgery and Turbinectomy (Septoplasty, Nasal Airway Surgery). In: Davis CP, ed. MedicineNet. New York: WebMD; November 15, 2019.
6. Webster AC, Morley-Forster PK, Janzen V, et al. Anesthesia for Intranasal Surgery: A Comparison Between Tracheal Intubation and the Flexible Reinforced Laryngeal Mask Airway. Anesthesia & Analgesia. 1999;88(2):421–425.
7. Johns Hopkins Medicine. Post Operative Instructions. Otolaryngology-Head and Neck Surgery 2020; https://www.hopkinsmedicine.org/otolaryngology/specialty_areas/sinus_center/procedures/post_operative_instructions.html.
8. Kaplan A, Crosby GJ, Bhattacharyya N. Airway Protection and the Laryngeal Mask Airway in Sinus and Nasal Surgery. The Laryngoscope. 2004;114(4):652–655.
9. Kim HJ, Kim DK, Kim HY, Kim JK, Choi SW. Risk factors of emergence agitation in adults undergoing general anesthesia for nasal surgery. Clinical and Experimental Otorhinolaryngology. 2015;8(1):46–51.
10. Kazak Z, Meltem Mortimer N, Şekerci S. Single dose of preoperative analgesia with gabapentin (600 mg) is safe and effective in monitored anesthesia care for nasal surgery. European Archives of Oto-Rhino-Laryngology. 2010;267(5):731–736.
11. Karaaslan K, Yilmaz F, Gulcu N, Colak C, Sereflican M, Kocoglu H. Comparison of dexmedetomidine and midazolam for monitored anesthesia care combined with tramadol via patient-controlled analgesia in endoscopic nasal surgery: A prospective, randomized, double-blind, clinical study. Current Therapeutic Research. 2007;68(2):69–81.
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13. Lormans P, Gaumann D, Schwieger I, Tassonyi E. Ventricular fibrillation following local application of cocaine and epinephrine for nasal surgery. ORL. 1992;54(3):160–162.
14. Chiu YC, Brecht K, DasGupta DS, Mhoon E. Myocardial Infarction With Topical Cocaine Anesthesia for Nasal Surgery. Archives of Otolaryngology–Head & Neck Surgery. 1986;112(9):988–990.
15. Dwyer C, Sowerby L, Rotenberg BW. Is cocaine a safe topical agent for use during endoscopic sinus surgery? The Laryngoscope. 2016;126(8):1721–1723.