Rhinoplasty

Anesthesia Implications

Position: Supine, Bed turned 90 degrees, Bed turned 180 degrees
Time: 1-2 hours (average)
Post-op Pain: Minimal (1-3)
Maintenance Paralytic: No

Sleep Apnea – Patients with nasal obstruction may also have a sleep apnea – so it’s recommended to assess for this in preop.

Approach – LMA is typically preferred as it protects the esophageal inlet and bleeding in the nasopharynx is usually expected. If an ETT is used, a throat pack is placed to prevent blood from entering the stomach. TIVA with propofol at 80-150 mcg/kg/min and remifentanil (0.1-0.25mcg/kg/min) is preferred over inhalation GA due to decreased risk of PONV and improved hemodynamic stability. Secure the tube to the midline of the lower lip. Some surgeons may request an oral RAE or reinforced ETT.

Treat swelling – Corticosteroid:4-8mg IV decadon

Antibiotic – Typically cefazolin

Extubation Preparation – Suction stomach via OG tube at the end. Throat pack needs to be removed prior to extubation.

Emergence and Extubation – Smooth emergence and the prevention of PONV are key. Typically best to deep-extubate where not contraindicated. Prevent bucking and coughing on extubation as they can result in bleeding under the septal skin flaps. After the patient is extubated, place an O2 mask on the patient that has been cut so that it does not come in contact with the nose. Nasal passages may be packed at the end of the procedure and the patient will become an obligate mouth-breather.

180 degree turns (general considerations): Arrange lines and monitor cords in anticipation to turn. If turning right, keep cords and lines draped to the left. If turning left, keep cords and lines draped to the right. Have a circuit extension connected. Disconnect the circuit when turning and immediately reconnect.

Rhinoplasty is the surgical manipulation of the nose for either aesthetic or functional improvement.

During a rhinoplasty, the tip of the nose is remodeled, the nasal hump is reduced, or bony osteotomies are performed to remodel the contour of the nose. In order to improve the airway, surgery on the inferior turbinates is performed to resect the turbinate bones and mucosa. The approach can be either intranasal or extranasal, but intranasal is more common. After the surgery is finished, the nasal cavities are packed and external splints may be used. The nasal packing can be removed at 24-72hrs postop.