The patient with ear, nose, and throat (ENT) dysfunction presents many challenges to the perianesthesia nurse. These patients often have a difficult airway for management (see Chapter 30), which in itself can be challenging. The patient emerging from maxillofacial surgery, which usually consists of dental or jaw surgery, requires close monitoring of airway patency and clearance. Additionally, the nurse must be prepared to manage the pain associated with those surgical procedures in a way that does not depress respiratory status. The perianesthesia nurse needs a strong knowledge of airway anatomy and physiology and excellent skills in the management of a difficult airway. Finally, the perianesthesia nurse must also be prepared to address the behavioral component of patients who undergo ENT or maxillofacial surgery. Patients undergoing these procedures may experience multiple emotions, from fright because of wiring of the jaw, fear because of the tight bandaging, claustrophobia from nasal packing, grief related to loss of function, and associated pain. Chapters 12 and 30 offer comprehensive information on the respiratory system and airway management and can be used to supplement information in this chapter.
The patient with ear, nose, and throat (ENT) dysfunction presents many challenges to the perianesthesia nurse. These patients often have a difficult airway for management (see Chapter 30), which in itself can be challenging. These patients also often have abnormal or dysfunctional anatomy that presents major concerns and requires enhanced awareness. Familiarity with the “normal” anatomy of the structures associated with ENT surgical procedures is beneficial when caring for these patients. The patient emerging from maxillofacial surgery, which usually consists of dental or jaw surgery, requires close monitoring of airway patency and clearance. Additionally, the nurse must be prepared to manage the pain associated with those surgical procedures in a way that does not depress respiratory status. The perianesthesia nurse needs a strong knowledge of airway anatomy and physiology and excellent skills in the management of a difficult airway. Finally, the perianesthesia nurse must also be prepared to address the behavioral component of patients who undergo ENT or maxillofacial surgery. Patients undergoing these procedures may experience multiple emotions, from fright because of wiring of the jaw, fear because of the tight bandaging, claustrophobia from nasal packing, grief related to loss of function, and associated pain. Chapters 12 and 30 offer comprehensive information on the respiratory system and airway management and can be used to supplement information in this chapter.
Ankyloglossia (Tongue Tied)A short lingual frenulum that may cause difficulty with suckling in the infant and subsequent speech impairment. It is treated surgically with clipping of the frenulum.
Balloon SinuplastyMinimally invasive surgical procedure used to re-establish patency to the sinus ostia using balloon catheters.
Cochlear ImplantInvasive procedure in which a prosthesis with an internal electrode is surgically implanted into the cochlea so that an external microphone later can be applied for stimulation of the eighth cranial nerve and provision of sound for a deaf person.
EndoscopyNoninvasive procedure used to visualize structures. Endoscopes, both flexible and rigid, are used, depending on the structure (e.g., nasal cavity, larynx, esophagus, etc.) being assessed.
EthmoidectomyRemoval of ethmoid sinus cells and bone.
FenestrationAny naturally occurring or artificial opening in an object or the anatomy. In ENT surgery, fenestration may be used to help aerate the sinus cavity or in the labyrinth of the inner ear to improve hearing.
Functional Endoscopic Sinus Surgery (FESS)Minimally invasive surgical treatment of sinusitis and nasal polyps. Endoscopes and small articulating instruments are used to identify and restore proper drainage and ventilation structures within the nasal and sinus cavities.
GlossectomyRemoval of the tongue.
LaryngectomyRemoval of the larynx; total laryngectomy is the complete removal of the cartilaginous larynx, the hyoid bone, and the strap muscles connected to the larynx and the possible removal of the pre-epiglottic space along with the lesion.
LaryngofissureOpening of the larynx for exploratory, excisional, or reconstructive procedures.
LaryngoscopyDirect examination of the interior of the larynx with a laryngoscope.
MastoidectomyRemoval of mastoid air cells and of the tympanic membrane. Radical mastoidectomy also involves removal of the malleus, incus, chorda tympani, and mucoperiosteal lining.
MyringotomyIncision of the tympanic membrane. Pressure-equalizing tympanostomy tubes are often placed through the incision for facilitation of drainage.
OssiculoplastyReconstruction of the ossicular chain in the ear.
RhinoplastyCorrection and/or modification of the internal structure of the nose (e.g., nasal cartilage and bone) for functional and or esthetic purposes.
Semi-Fowler PositionInclined position with the upper half of the body raised with elevation of the head of the bed by approximately 30 degrees.
Sensorineural Hearing LossThe sound is conducted normally through the external and middle ear, but a defect in the inner ear or auditory nerve results in a loss or deficit in hearing.
SeptoplastyRemoval of either cartilaginous or osseous portions of the septum that lie between the flaps of the mucous membrane and the perichondrium for establishing an adequate partition between the left and right nasal cavities, thereby providing a clear airway for both the internal and the external cavities and the parts of the nose.
SplintsDevice placed internally or externally to immobilize structures. In nasal surgery, silicone splints may be placed internally to maintain alignment. Fiberglass or plaster splints are placed externally over the nose to reduce edema and help mold nasal tissue.
StapedectomyRemoval of the stapes followed by the placement of a prosthesis.
StentsA rod or tubular support used to maintain patency of a structure or vessel.
Submucosal ResectionRemoval of either cartilaginous or osseous portions of the septum that lie between the flaps of the mucous membrane and the perichondrium for establishing an adequate partition between the left and right nasal cavities, thereby providing a clear airway for both the internal and the external cavities and the parts of the nose.
Tonsillectomy and Adenoidectomy (T&A)Surgical removal of the tonsils and adenoids.
TracheostomyOpening of the trachea and insertion of a cannula through a midline incision in the neck below the cricoid cartilage.
TurbinectomyRemoval of the nasal turbinates; often performed in conjunction with septoplasty.
Tympanoplasty (Myringoplasty)Reconstruction of the tympanic membrane.
UvulopalatopharyngoplastySurgical treatment for obstructive sleep apnea involving the removal of both tonsils (if present), removal of the uvula, and reduction of the distal end of the soft palate.
Otologic surgery has been revolutionized by antibiotics, the operating microscope, new and more delicate instruments, and an increased understanding of the anatomic structures involved (Fig. 32.1). New methods have been devised for the surgical treatment of hearing loss with correction of conduction apparatus abnormalities, and selected patients can now be surgically relieved of the disabling symptoms of sensorineural hearing loss.
Most otologic procedures are performed as an outpatient procedure. The immediate postanesthesia care for patients who have undergone surgery on the ear is generally the same regardless of the procedure. Immediate postoperative complications are rare. Occasionally, excessive bleeding may occur, especially if a large blood vessel has been entered during the operation. Complications such as this should be reported in the handoff report to the postanesthesia care unit (PACU) nurse who will complete an immediate postanesthesia assessment. In addition to a standard assessment, testing for function of the facial nerve should be performed. The patient should be instructed to smile enough to show teeth, wrinkle the forehead, wrinkle the nose, squeeze eyelids shut, stick out tongue, and pucker the lips.1 An inability to perform these actions indicates injury to the facial nerve and should be appropriately indicated in the patient’s medical record and reported to the surgeon.
If surgery has been performed near the brain (e.g., the inner ear), check for clear fluid in the ear or on the dressings that may indicate cerebrospinal fluid leakage. Use of aseptic technique for all dressing assessment and protection from infection are especially important elements in the care of the patient who has undergone surgery on the ears, because infection can be transmitted easily to the meninges and the brain. The outer ear is highly vascular and susceptible to circulatory damage and excoriation. The outer ear may even become necrotic if circulation is impaired by poor positioning or excessive pressure of a dressing. Assessment of the dressing should therefore include proper positioning.1,2
Positioning of the postanesthesia patient who has undergone ear surgery should be indicated by the surgeon. If position is unimportant, the patient should be allowed to assume a position of comfort, usually with the head of the bed elevated to facilitate drainage. Generally, lying on the unoperated side is most comfortable for the patient.
Nausea, vertigo, and nystagmus are common in patients after ear surgery. The patient may minimize discomfort by remaining in the position ordered, moving slowly, and avoiding quick jerky movements.1,2 The patient should be advised to take slow, deep breaths through the mouth to minimize nausea. Antiemetic drugs and sedatives such as a 5-HT3 antagonist (e.g., ondansetron [Zofran]) may be ordered for prevention or treatment of nausea and vertigo. The nurse should avoid jarring the bed. When approaching the patient, the nurse should place a hand on top of the patient’s head as a reminder not to turn suddenly when the nurse speaks. Sudden turns should be avoided, and movement should be slow in patient transport. Particular attention must be paid to maintaining the integrity of the airway should nausea and vomiting occur.
Patient education should include not allowing water in the ears such as with swimming or during showering/hair washing. Special ear plugs can be purchased; some surgeon’s offices offer custom fit ear plugs. Instructions should also include not blowing the nose forcefully, especially in the case of myringotomy with tube placement. Surgeons have varying preferences regarding these instructions; therefore, care should be made to give instructions pertinent to that specific practitioner.
Myringotomy is the most common procedure performed on infants and small children; it is performed for otitis media related to eustachian tube dysfunction. The procedure may also be performed in adults for similar reasons or for barotrauma or hyperbaric chamber treatment. Children will often exhibit frequent ear infections or symptoms of pain, poor coordination, hearing loss, or speech delays.3
During the procedure, and after a hole in the tympanic membrane is created with a myringotomy blade, the surgeon will place a pressure-equalizing tube to maintain patency. There are several types of tubes available, and they are placed according to the surgeon’s preference.4
Special pediatric considerations must be given in the immediate postanesthesia phase specific to airway management, safety, parental involvement, and outpatient teaching.1 This procedure is commonly bilateral in children; however, in adults it is commonly unilateral.3 A small piece of sterile cotton can be placed loosely in the external ear to absorb the drainage that commonly occurs. The cotton should be changed when saturated to avoid contamination.
Patients with chronic otitis media and mastoiditis are common indications for a mastoidectomy. A mastoidectomy may also be needed as a first step to placing a cochlear implant.5 A firm, bulky pressure dressing is placed over the ear and held in place with a circular head bandage after mastoidectomy.4 This dressing may be reinforced, if necessary, but it should be changed only by the physician. Minimal serosanguineous drainage may be expected, but bright bloody drainage should be reported to the surgeon. The patient should be placed in a position of comfort, usually on the nonoperative side, typically in a semi-Fowler position. Facial nerve assessment is recommended. Dizziness and vertigo are common after mastoidectomy and can be treated with the previously mentioned measures.1,2
Patients are usually positioned on the unoperated side after tympanoplasty. Care must be taken to keep bandages and grafts in place. Patients should be instructed not to blow the nose or cough and to avoid sneezing to prevent disruption of the grafts. Instruct the patient to open the mouth if sneezing occurs so that the force of the sneeze has a larger exit opening, keeping the pressure out of the eustachian tubes.
Patients who have undergone stapedectomy are usually admitted to the PACU with ear packing in place; this packing should not be disturbed.4 Occasionally, patients have vertigo after surgery. Patients should be advised to avoid blowing the nose, coughing, and sneezing.
Damage to hair cells in the cochlea resulting in deafness is the most common reason a cochlear implant is needed. The implant will stimulate the nerve and send sound to the brain1 (Fig. 32.2). Patients who have undergone a cochlear implant need the same postanesthesia care as any other patient for ear surgery. Verification of the integrity of the facial nerve is important. These patients do not have hearing immediately after surgery and need emotional support and a means of communication such as pen and paper, white board and markers, or a sign language interpreter.1
Nasal and sinus surgery can be accomplished with local or general anesthesia. The disposition of the patient is determined by the nature and type of surgery as well as the anesthesia used for the procedure. Although no longer common with the use of endoscopic procedures, overnight observation of the patient in an inpatient setting may be necessary before discharge from the hospital. An inpatient stay may be considered for patients with comorbidities such as obstructive sleep apnea because they will have some difficulty with use of the continuous positive airway pressure (CPAP) machine owing to the nasal splints or packing.6 The anatomy of the nasal cavity is shown in Fig. 32.3.
Patients admitted to the PACU after nasal surgery, such as septoplasty, rhinoplasty, functional endoscopic sinus surgery, or balloon sinuplasty, should be placed in a semi-Fowler position to promote drainage, reduce local edema, minimize discomfort, and facilitate respiration. Some postoperative serosanguineous drainage is expected; however, the nurse should observe closely for gross bleeding.2 Loss of vision is a complication that may indicate intraoperative breach of the orbital cavity and requires immediate attention by the surgeon. The patient is usually admitted with one or both nostrils packed and a mustache dressing in place to absorb any drainage from the packing.4 The position of the nasal packs and the amount of drainage should be checked frequently as packs may shift, causing airway obstruction. The mustache dressing may be changed as necessary; two or three changes within a 4-hour period are not unusual. Another method commonly used to facilitate postoperative drainage is the insertion of nasal stents. This approach affords more comfort and permits nasal breathing.
The back of the patient’s throat should be checked frequently for blood. Frequent swallowing, belching (from the accumulation of blood in the stomach), nausea, and the classic signs of hemorrhage, such as tachycardia, are additional indicators of bleeding.1 The patient should be instructed not to blow the nose or swallow secretions but to expectorate them into a basin. An ample supply of disposable tissues along with an emesis basin or bag should be placed within easy reach of the patient.
Oral fluids are typically limited until bleeding is controlled, vomiting and nausea have subsided, and independent airway management has been established. Antiemetics are ordered to alleviate nausea and vomiting when needed.
Mouth breathing, bleeding, and postnasal drainage create dryness and an offensive taste and odor in the patient’s mouth; therefore, once the gag reflex has returned, oral hygiene is a priority. Oral swabs or a continuous humidified air flow may be used for mouth care and to make the patient more comfortable. If oxygen is needed along with the humidified air, it should be delivered via cool mist mask through a face tent. Dry mucous membranes often produce coughing, dyspnea, and decreased respiratory exchange. Ice chips may be a comfort measure if intake is warranted.
Additional comfort measures include ointment to the lips to prevent drying and cracking and ice packs across the nose or to the cheeks to minimize pain, edema, discoloration, and bleeding. These ice packs should be small and lightweight and have a covering to prevent pack sweating or frostbite to patient skin.
When assessing the patient for pain and discomfort, the nurse should inquire about pain in the roof of the mouth and front teeth; this occurs from the edema underneath the septum. Most patients will complain of burning in the nose and a headache similar to the pain they experienced with sinus pressure before surgery.
The tongue occupies a large portion of the floor of the mouth. Surgery on the tongue generally involves excision of benign or malignant lesions, correction of congenital anomalies, or repair of traumatic lacerations. Lesions may be excised without associated neck dissection; however, when the lesion is malignant, surgical treatment usually involves a combined operation that may include radical neck dissection and resection of both the mandible and the tongue.2,4
Local anesthesia is used for minor surgical procedures such as excision of lesions and repair of lacerations. More extensive surgical procedures on the tongue or procedures in children (e.g., for ankyloglossia) require general anesthesia with endotracheal or nasotracheal intubation.
After surgery, maintenance of the airway is the most crucial concern. Suction needs to be available and the patient must be placed in a side-lying position with the head slightly dependent to allow for the drainage of secretions out of the mouth. Swelling of the tongue can occur and obstruct the airway; therefore, frequent assessment is required. When protective reflexes have returned, the patient should be placed in a sitting position to promote venous and lymphatic drainage.
Because of the vascular nature of the tongue and oral cavity, postoperative bleeding may be a problem. If excessive bleeding occurs, local pressure should be applied until the surgeon can be notified and repair can be performed in the operating room.
Surgery on the throat and neck is usually accomplished with general anesthesia. Aside from routine care and assessment, specific postanesthesia care for the patient who has undergone surgery on the throat involves: (1) close observation for bleeding from the surgical site, (2) maintenance of a patent airway, (3) prevention of aspiration of secretions, and (4) awareness of possible cerebral neurologic complications that may develop.
The most common procedures are tonsillectomy, either alone or in combination with adenoidectomy, and tracheostomy. Other procedures performed on the throat include laryngoscopy with or without biopsies, laryngectomy, palatoplasty, uvulectomy, and uvulopalatopharyngoplasty.
Most patients who undergo tonsillectomy (Fig. 32.4) and adenoidectomy (T&A) are children and young adults. However, the number of young children who undergo T&A continues to be reduced each year as a result of improved antibiotic treatment and compliance with health care guidelines. The American Academy of Otolaryngology—Head and Neck Surgery provides a guideline for the necessity of tonsillectomy in children, for the purpose of recurrent infections as well as obstructive sleep apnea concerns.7 Patients who have undergone T&A and are admitted to the PACU alert and oriented can be positioned on their backs with the head elevated 45 degrees. Patients who return after general anesthesia and are unconscious or semiconscious must be placed in the tonsillar position—well over on the side with the face partially down. The Trendelenburg position can be used to facilitate drainage. The patient’s airway and chest expansion must be in full view of the nurse to ensure maximal respiratory integrity at all times. In this position, secretions are easily drained from the mouth.2 An oral airway should be left in place until the swallowing reflex has returned and the patient can handle secretions. The patient should be advised to expectorate secretions as much as possible and to try not to cough, clear the throat, blow the nose, or talk excessively. An ice collar can be applied to minimize pain and postoperative bleeding. The administration of cool humidified air to the patient after T&A provides comfort, helps to minimize swelling, and supplies oxygen. As soon as oral intake is permitted, ice chips should be offered to moisten the throat and reduce swelling.