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Anesthesia for Otolaryngologic Surgery Edited by Basem Abdelmalak and D Cambridge University Press 978-1-107-01867-9 - Anesthesia for Otolaryngologic Surgery Edited by Basem Abdelmalak and D. John Doyle Excerpt More information Section 1 Introduction Chapter Clinical head and neck anatomy 1 for the ENT anesthesiologist Nicole M. Fowler and Joseph Scharpf Introduction plan including the use or avoidance of long-acting muscle relaxants for the case. The huddle process also An understanding of anatomy is paramount to the ensures that both the anesthesiologist and surgeon are ability to safely anesthetize the head and neck sur- present and ready to handle any potential periopera- gery patient. In contrast to other patient populations, ' tive complications. The head and neck surgeon the head and neck surgery patient s pathology may should be considered an airway specialist and partner obfuscate normal anatomy and impede or even pre- with the anesthesiologist. vent the anesthesiologist from being able to intubate the patient. Furthermore, recognized anatomic vari- ations may complicate the anesthesiologist's man- Face anatomy agement of the patient. Cooperation among the The basic underlying structure of the face is formed entire operating team is the key to a successful oper- by the skull, facial bones and mandible (Figure 1.1). ation. The surgeon and anesthesiologist must discuss The skull is formed by a series of eight bones: the particular patient's anatomy and specific proced- paired parietal and temporal bones and single frontal, ural needs prior to each case. Potential airway man- occipital, sphenoid and ethmoid bones [1]. The facial agement options such as routine oral intubation, skeleton creates the anterior portion of the skull and nasotracheal intubation, awake fiberoptic intubation includes the orbits, nares, maxilla and mandible. The and even awake tracheotomy must be considered. face is formed by 12 uniquely shaped bones: paired Contemporary technological advances can enhance lacrimal bones, nasal bones, maxillae, zygomatic and this discussion by including photography and video- palatine bones and a single vomer and mandible. The graphy. For example, computerized imaging systems maxillae and mandible support the teeth (Figure 1.1). in use in modern operating rooms can be synchron- The teeth are numbered from superior right to left ized to a server in the otolaryngology clinic to allow and inferior left to right from 1 to 32 for adults and the review of both photographs and videos of lettered A–T in the same order for pediatric primary patients' airways and the extent that they have been dentition. Normal occlusion, also termed class altered through disease progression. While the added I occlusion, is defined by the mesiobuccal cusp of dimension of visual review integrated into the dis- the first maxillary molar impacting the mesiobuccal cussion can be an invaluable adjunct to this team groove of the first mandibular molar [2]. Class II approach, always bear in mind that conditions could occlusion, commonly referred to as retrognathic, have worsened significantly since the imaging was occurs when the mesiobuccal cusp of the first maxil- performed. lary molar impacts mesial to the groove (overbite). Patient safety concerns continue to be increasingly Class III occlusion, commonly referred to as prog- recognized as a vital component of modern health nathic, occurs when the mesiobuccal cusp of the first care. At the authors' institution we perform both an maxillary molar impacts distal to the groove operative “huddle” with the patient awake and a sur- (underbite). gical “time-out” prior to performing any procedure. Trauma resulting in facial fractures can compli- The huddle is an ideal time to review the intubation cate intubation. Mandibular fractures are usually Anesthesia for Otolaryngologic Surgery, ed. Basem Abdelmalak and D. John Doyle. Published by Cambridge University Press. 1 © Cambridge University Press 2013. © in this web service Cambridge University Press www.cambridge.org Cambridge University Press 978-1-107-01867-9 - Anesthesia for Otolaryngologic Surgery Edited by Basem Abdelmalak and D. John Doyle Excerpt More information Section 1: Introduction (A) Frontal bone Parietal bone Glabella Supraorbital notch Greater wing of sphenoid bone Orbital surface of frontal bone Nasal bone Temporal fossa Lacrimal bone Greater wing of sphenoid bone Inferior orbital fissure Perpendicular plate of ethmoid bone Zygomatic bone Infraorbital foramen Maxilla Vomer Mastoid process Temporal bone Ramus Anterior nasal spine Alveolar processes Mandible Angle of mandible Mental foramen Mental protuberance Figure 1.1. Anterior cranium and overlying facial topography. Artwork created by Emily Evans. paired and occur on opposite sides of the mandible. preparing to intubate a patient with a mandibular Fractures of the maxillae are commonly categorized fracture carefully evaluate the teeth as the tooth based on the Le Fort classification [3]. Le Fort roots are areas of bony weakness and may be I fracture is a horizontal fracture of the maxilla involved in the fracture. Orbital fractures com- superior to the alveolar process and the pterygoid monly of the inferior orbital rim may result in plates of the sphenoid. Le Fort II fractures involve entrapment of the extraocular muscles; particularly an oblique fracture of the maxillary sinus and hori- theinferiorrectuscanresultinactivationofthe zontal fractures of the lacrimal and ethmoid bones oculocardiac reflex [4]. This reflex between the acrossthenoseresultinginanunstablemidface trigeminal and vagus nerve can result in bradycar- where the hard palate is separated from the skull. dia, a junctional rhythm, asystole or even death. Le Fort III fractures involve a horizontal fracture Treatment includes surgical release of the muscle, through the superior orbital fissure, the ethmoid atropine or glycopyrrolate. and nasal bones through the greater wing of the Face shape is determined by the bones, muscles sphenoid bone and frontozygomatic sutures. This and subcutaneous tissue (Figure 1.2). The muscles of may occur in conjunction with fractures of the facial expression lie within the subcutaneous tissue. zygomatic arches resulting in an unstable midface The muscles of facial expression are innervated by where the maxilla and zygomatic bones are no the facial nerve. They generally attach to bone or longer attached to the skull. If significant facial fascia and act by pulling the skin to create facial trauma has occurred the patient may have resulting expression. When performing surgery around the skull and brain injuries which may supersede treat- facial nerve or its branches, including otologic pro- ment of the facial injuries. Depending on the sever- cedures, parotidectomy, submandibular gland exci- ity of the trauma, the airway may have been triaged sion and neck dissections, neuromuscular blockage is in the field and an emergency cricothyroidotomy contraindicated and all or part of the ipsilateral face 2 or tracheotomy may have already been performed may need to be included in the surgical field for if an oral intubation was not possible. When monitoring. © in this web service Cambridge University Press www.cambridge.org Cambridge University Press 978-1-107-01867-9 - Anesthesia for Otolaryngologic Surgery Edited by Basem Abdelmalak and D. John Doyle Excerpt More information Chapter 1: Clinical head and neck anatomy for the ENT anesthesiologist (B) Incisors 8 9 7 10 6 11 Canine Incisors 5 12 Bicuspids E F 4 13 D G Maxilla Canine C H 3 14 B I 2 15 Molars Maxilla Molars A J 1 16 T K 32 17 Molars Mandible S L 31 18 Molars Mandible Canine R M 30 19 Q N P O 29 20 Bicuspids Incisors 28 21 27 22 Canine 26 23 25 24 Incisors Figure 1.1. (cont.) Ear anatomy containing the saccule and utricle, which along with the semicircular canals control balance. The labyrin- The ear is divided into three parts: the external, thine and tympanic portions of the facial nerve lie in middle and internal. The external ear (Figure 1.3) close proximity to these structures and may be dehis- includes the external auditory canal to the tympanic cent, necessitating lack of neuromuscular blockade membrane. This is approximately 2–3 cm in length. and close monitoring of facial movements during The lateral one-third is cartilaginous and the inner certain otologic procedures. two-thirds is composed of skin directly on the perios- teum of the tympanic portion of the temporal bone. The middle ear is an air-filled cavity containing the Nose anatomy three auricular ossicles – the malleus, incus, and The nose projects from the face largely based on the stapes. The middle ear pressure is regulated by the amount of cartilage. Extending from the nasal bone eustachian tube, which opens into the nasopharynx. are the upper and lower lateral cartilages. Stability is The inner ear is contained within the petrous portion provided from the underlying nasal septum which is of the temporal bone and includes the cochlea, vesti- also composed of both bone and cartilage. The pos- bule and semicircular canals. The cochlear hair cells terior bony septum is formed from the perpendicular activate the cochlear nerve, resulting in hearing trans- plate of the ethmoid and vomer but the majority of 3 mission. The vestibule is a small oval chamber the septum, the anterior septum, is the quadrangular © in this web service Cambridge University Press www.cambridge.org Cambridge University Press 978-1-107-01867-9 - Anesthesia for Otolaryngologic Surgery Edited by Basem Abdelmalak and D. John Doyle Excerpt More information Section 1: Introduction Frontalis Temporalis Procerus Orbital part Orbicularis oculi Palpebral part Levator labii superioris Nasalis aleque nasii Zygomaticus minor Levator labii superioris Zygomaticus major Orbicularis oris Risorius Masseter Depressor anguli oris Depressor labii inferioris Sternocleidomastoid Mentalis Platysma Figure 1.2. Muscles of facial expression. Artwork created by Emily Evans. cartilage. The nasal ala are supported by U-shaped supply. The anterior nasal septal area is referred to alar cartilage which is free and mobile, allowing the as Kiesselbach's plexus and is the site of a capillary dilatation or constriction of each nostril.
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