Return to: Otology - Neurotology

Anesthesia Considerations

1. Positioning/monitoring
   • BP cuff on contralateral side to surgery
   • Advise anesthesia that we will be turning 180 degrees
     • Have circuit extensions available
     • They can work on extra IV lines or arterial lines after rotating bed
       • Allows both teams to work on patient simultaneously
       • Eliminates tangling of lines if placed after rotating bed
2. Anesthetic agents
   • Advise the need for "no paralysis" during the case for facial nerve monitoring
     • Short-acting or no paralysis for induction/intubation
   • We recommend against the use of nitrous oxide when we plan on tympanic membrane grafting
3. ETT taped off of contralateral side to surgery
   • No tape past nasal ala
4. Maintain blood pressure with a systolic around 100 mm Hg

Patient Preparation and Positioning

1. Bed
   • "X-ray" riser removed from bed
   • Base of bed reversed (may depend on type of bed)
   • 3 sets of straps
2. Patient will be laid supine with head of patient 180 degrees from anesthesia
   • Rotate head so that surgical side is up
   • Reston ® or thin foam or gel pad under head
   • Towel roll under contralateral cheek to prevent hyperrotation and subluxation in pediatric/geriatric patients
3. Tucking/Padding
   • BOTH Arms are tucked into draw sheet with ulnar nerves well-padded
   • Low-profile elbow guards placed and padded
   • Three sets of straps:
     • Strap over chest + elbow guard
     • Strap over hip/upper thigh
     • Strap over lower leg
     • Avoid strap over knees or ankles
   • Double check arms and legs padding to ensure safety.
4. A "test roll" is performed after patient secured to bed.
5. Lower body Bair Hugger (Arizant Inc., Eden Prairie, Minnesota) only, if Bair Hugger desired by anesthesia personnel.
   • Full body Bair Hugger gets in the surgeon’s way
   • Possible need for abdominal fat harvest

NIMS Facial Nerve Monitor

1. Half-pieces of Tegaderm ®
2. Red = mouth
3. Blue = eye
4. Ground electrodes
   • Green above white
   • Set at least 1 cm apart
   • Only need one set of grounds if bilateral surgery
5. When securing NIMS to bed, ensure that the Prass probe insert is not covered and is accessible by nursing.
   • Do not allow cord to drag, as it is likely to get dislodged during surgery.
   • Tuck onto bed rails
6. Set up and tested according to manufacturer’s instructions

Intraoperative Auditory Brainstem Monitoring

1. 4 electrodes, two ear inserts
   • Red = right
     • Mastoid electrode
     • Ear insert
   • Blue = left
     • Mastoid electrode
     • Ear insert
   • White = crown of head
   • Green = forehead
2. Electrodes come off on the side of surgery
3. Ear inserts come off on the contralateral side of surgery

Medications

See OTOLOGY ANTIBIOTIC ADMINISTRATION GUIDELINES

• Local anesthetic
  • Adult strength: 1% lidocaine in 1:100,000 epinephrine
  • Pediatric strength: 0.5% lidocaine with 1:200,000 epinephrine
  • Canal injection under general anesthesia: 1:20,000 plain epinephrine
  • Canal injection under local anesthesia: 1:20,000 plain epinephrine + 1% lidocaine