What is the best Anesthesia for a septo-rhinoplasty?

Dear JK123;



If you
are having both a rhinoplasty and a septoplasty and even possibly turbinate
resection to improve your airway, the choice of anesthesia is between two
techniques.The two techniques are:



1. General endotracheal anesthesia.



2. LMA (laryngeal mask anesthesia) with local
block anesthesia by a surgeon.



The third
option, straight local anesthesia without an airway is not advisable because
nasal surgery can have unpredictable bleeding and blood flowing into the larynx
and upper air passages during surgery; it's never a good idea. Hence, the preference for the technique 
in which the upper airway is protected either by the oral endotracheal airway
tube or the laryngeal mask. Both are inserted by the anesthesiologist
after a sleep dose of medication is given so that you are not aware of the
placement of either device.



Today,
anesthesia for nasal surgery is safer than ever. I know because I have over 40 years of
history to judge from. In the early
days of my practice, because general anesthesia was not as safe, we generally
did cases under local anesthesia with sedation. Frankly, it was not a safe
nor a pleasant experience for the patient, but today, computerized monitoring
and the use of the laryngeal mask anesthetic has made nasal surgery much safer, more simple and practical.



My
anesthesiologist with whom I work very closely the last 16 years, does an
excellent job using the laryngeal mask anesthesia.The sequence is as follows:The patient arrives at the surgery center and
receives a 10 mg dose of Valium for relaxation and to provide the ideal condition
for the beginning of the anesthetic. An
intravenous line is then placed with a little bit of anesthetic injected into
the skin. Another intravenous line is inserted into the most accessible vein, then the patient is taken to the
operating room and a little bit more sedative can be given in the holding area
intravenously so the patient is in a very quiescent, comfortable and mildly
sleepy state.



The
formal anesthetic in the operating room begins with a dose of propofol. Propofol, despite the tragedy of Michael
Jackson, remains the mainstay of modern anesthesiology because it is a drug
that puts you to sleep and detaches you from the environment without the risk
of compromising pulse, blood pressure and heart rate, per se. Once you are asleep with the propofol, then
the surgeons inject local anesthetic inside the nose to block all the nerves
and reduce bleeding. The local
anesthetic has a dilute solution of epinephrine to shrink the blood vessels;
otherwise, the surgery would be so bloody as to be beyond performance.



The
combination of being asleep yet not totally unconscious and the
combination of local anesthetic plus the propofol-induced sleep renders a
perfect and safe situation. One does not
need to have a full general anesthetic whereby the breathing and other bodily
functions are more under the control of medications. Fewer medications is the key. We do not need to have the patient paralyzed,
as is the future of general anesthesia. All we need is a patient who is unaware and not apt to move or wake up
during the procedure. Pain control is
rendered by the local anesthetic which is still onboard when the patient
emerges from the procedure in the recovery room. It's a wonderful combination because of its
safety, efficiency and, generally, freedom from side-effects. We rarely see nausea and vomiting in the
recovery room now. The key is an
anesthesiologist who does this work everyday and is part of the team of the
super-specialized nasal functional and cosmetic surgeon. You need a team just as you need a team for
heart surgery and in basketball. Teams perform
well when they work together on a daily basis.



Regarding minimizing pain afterwards: generally, it is not very painful. Generally, patients just take low-dose of
Tylenol with Codeine or something like Vicodin for a few days, if needed. Some take only a nonsteroidal
antiinflammatory. The nose does not move
and, therefore, it is not subject to the discomfort which would accompany
surgeries performed on moving parts elsewhere on the body.



We always
recommend that patients speak with our anesthesiologist before surgery or even
as far as a consultation. It makes sense.



You are
wise in considering the anesthetic issue.



Best wishes,
Robert
Kotler, MD, FACS

In our practice we perform both septoplasty and rhinoplasty under general anesthesia. For patient's safety and comfort board-certified Physician anesthesiologists are in attendance throughout the entire  procedure. We do not recommend sedation due to pooling of blood in the back of the throat that can  get into the lungs. In addition, patient's will have conscious awareness of the procedure including osteotomies or breaking the nose. For many examples, please see the link below

This varies by the surgeon and anesthesia provider. I trained at one institution (University of Michigan) where the CRNAs provided excellent sedation for nasal surgery. However, this is the exception to the rule and I've never found another hospital or surgery center that was able to provide excellent IV sedation for this type of surgery. Therefore, I do all of these cases under general anesthesia. The accredited ASC where I operate uses an LMA as opposed to endotracheal tubes for patients that do not have severe reflux. This works very nicely as long as your surgeon is very cognizant of any bleeding into the back of the nose. Once you've chosen a surgeon that you trust and that creates beautiful results, seriously consider their recommendation as to which type of anesthesia will give you the best and safest experience. I hope this information is helpful for you.Stephen Weber MD, FACSDenver Facial Plastic Surgeon