History, Physical Examination, and the Preoperative Evaluation

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CHAPTER 8 History, Physical Examination, and the Preoperative Evaluation

Marion Everett Couch

Key Points

• In patients with head trauma, postauricular ecchymosis (or Battle’s sign) suggests that a temporal bone fracture may have occurred.
• The pretracheal, paratracheal, precricoid (Delphian), and perithyroidal nodes are contained in level VI, which extends from the hyoid bone to the suprasternal region.
• A Virchow node, often a left supraclavicular node associated with visceral metastasis, is not in the VB region but is located in level IV.
• When removing cerumen, remember that the canal is well supplied with sensory fibers: CN V3, the auricular branch of CN X, C3, and CN VII. CN X is also the source of referred throat pain to the ear.
• The tympanic membrane is oval, not round, and has a depressed central part called the umbo, where the handle of the malleus attaches to the membrane.
• This superior flaccid area is critical to examine carefully because retraction pockets may develop here, which may develop into cholesteatomas.
• In congenital cholesteatomas, often diagnosed in young children, the tympanic membrane is intact and a white mass is seen in the anterior superior quadrant. In contrast, acquired cholesteatomas in adults are often in the posterior superior quadrant and are associated with retraction pockets, chronic otitis media with purulent otorrhea, and tympanic membrane perforations.
• A midline Weber result is referred to as “negative.” “Weber right” and “Weber left” refer to the direction to which the sound lateralized.
• To compare air conduction with bone conduction, perform the Rinne test using the 512-Hz tuning fork placed by the ear canal and then on the mastoid process. A “positive test” result is air conduction louder than bone conduction.
• While examining the buccal membranes, note the location of the parotid duct, or Stensen’s duct, as it opens near the second upper molar.
• Small yellow spots in the buccal mucosa are sebaceous glands, commonly referred to as Fordyce spots, and are not abnormal.
• The hard palate may have a bony outgrowth known as a torus palatinus.
• The point wherein numerous small branches of the external and internal carotid arteries meet, or Kiesselbach’s plexus, is the most common site for epistaxis.
• Risk factors for a perioperative cardiovascular complication include jugular venous distention, third heart sounds, recent myocardial infarction (MI) (within 6 months), nonsinus heart rhythm, frequent premature ventricular contractions (>5 per minute), age older than 70 years, valvular aortic stenosis, previous vascular or thoracic surgery, and poor overall medical status.
• The term thyroid storm refers to a life-threatening exacerbation of hyperthyroidism that results in severe tachycardia, fever, and hypertension.
• Treatment of hyperthyroidism attempts to establish a euthyroid state and to ameliorate systemic symptoms.
• Chvostek’s sign (facial nerve hyperactivity elicited by tapping over the common trunk of the nerve as it passes through the parotid gland) and Trousseau’s sign (finger and wrist spasm after inflation of a blood pressure cuff for several minutes) are clinically important indicators of latent hypocalcemia.
• Congenital deficiencies of hemostasis affect up to 1% of the population.
• Preoperatively, the platelet count should be greater than 50,000; at levels below 20,000, spontaneous bleeding may occur.
• Severe azotemia secondary to renal failure may lead to platelet dysfunction (uremic platelet syndrome). Dialysis should be performed as necessary.
• Approximately 50% of all postoperative deaths in older adults occur secondary to cardiovascular events, thus severe cardiac disease should be treated before any elective procedure and should be weighed against the benefit of any more urgent procedure.

A physician is privileged when requested to evaluate a person and render an opinion and diagnosis. The importance of obtaining an accurate, detailed patient history cannot be overemphasized because it is the framework upon which the otolaryngologist places all available information. Without this, the evaluation may be incomplete and the diagnosis flawed. Unnecessary testing may ensue, and at a minimum, a delay in symptom management may result. In the worst scenario, a misdiagnosis may occur. Therefore the energy expended in obtaining a complete history is always worthwhile.

Preoperative evaluation of surgical patients is, in its broadest sense, an extension of the diagnostic process. The surgeon should (1) strive to determine the extent of disease, (2) prove the necessity of surgery or clearly demonstrate its benefit to the patient, (3) optimize the choice of surgical procedure, and (4) minimize the risk to the patient by defining concomitant health problems and instituting appropriate therapy or precautionary measures. Integral to each of these goals is an appreciation of the ideal set forth in the Hippocratic Oath—above all else, do no harm. It is the surgeon’s responsibility to ensure that an appropriate patient assessment has been completed before entering the surgical suite. Surgical complications can often be avoided by recognizing the physiologic limitations of the patient preoperatively. Documentation of findings, decision making, and discussion between surgeon and patient regarding surgical risks and benefits have become medicolegal imperatives.

Gathering a Patient History

The otolaryngologist should always try to request that previous medical records pertaining to the patient’s current problem be sent to the office before the visit. If previous operations have been performed, operative reports can be important sources of information. In addition, pertinent radiographic imaging is helpful to obtain for review. Reports of computed tomography (CT) or magnetic resonance imaging (MRI) scans are valuable but cannot substitute for actual review of the imaging by the otolaryngologist. For head and neck cancer patients, any pathologic slide specimens from past biopsies should be sent to the pathology department for review so that a second opinion may be rendered. This is especially helpful when patients are referred with an unusual pathologic diagnosis. Finally, laboratory values can provide much information and should be carefully reviewed.

The physician should address the patient’s chief complaint by determining its duration, intensity, location, frequency, factors that make the problem worse or better, any past therapy, and related symptoms. Whether the complaint is vertigo, pain, sinusitis, hearing loss, allergies, or a neck mass, the approach should entail asking many of the same basic questions followed by more specific ones designed to elucidate the full scope of the problem.

A discussion of the patient’s medical history not only leads the otolaryngologist to a better understanding of the patient, but also often reveals pertinent information. For instance, a patient with an otitis externa who also is diabetic requires a high level of concern for malignant otitis externa, which may be reflected in the management plan. If the patient requires surgery, complete knowledge of the patient’s medical problems is necessary before the operative procedure.

The surgical history is equally valuable. All the past operations of the head and neck area are important to note, including surgery for past facial trauma, cosmetic facial plastic surgery, otologic surgery, and neoplasm. However, full disclosure of all past operations may be critical. The otolaryngologist needs to know whether a patient scheduled for surgery has had adverse reactions to anesthetic agents or a difficult intubation.

Any known drug allergies and side effects are crucial to note prominently in the medical chart. True allergies should be distinguished from side effects of a medication. In addition, all medications and current dosages should be accurately recorded. Often it is valuable to inquire whether the patient has been compliant with the prescribed medication regimen because the physician needs to know what dose the patient actually is taking.

It is also advantageous to assess for risk factors associated with certain disease states. Tobacco use is important to note. It is helpful to specifically ask about cigarette, cigar, and chewing tobacco consumption—either current or past use. Alcohol consumption also is occasionally difficult to quantitate unless the interviewer asks direct questions regarding frequency, choice of beverage, and duration of use. Recreational drug use should be addressed, as should risk factors for communicable diseases such as the human immunodeficiency virus (HIV) and hepatitis virus. For patients being assessed for hearing loss, major risk factors such as exposure to machinery, loud music, or gunfire should be discussed. Finally, past irradiation (implants, external beam, or by mouth) and dosage (either high or low dose) should be ascertained. A history of accidental radiation exposure also is important to document.

The patient’s social history should not be overlooked because it may often reveal more occult risk factors for many diseases. For instance, a retired steel worker may have an extensive history of inhaling environmental toxins, whereas a World War II veteran may have noise-induced hearing loss from his or her military service. Family history often is equally revealing, and asking patients questions about their familial history of such conditions as hearing loss, congenital defects, atopy, or cancer may uncover useful information that they had not previously considered.

Finally, a review of systems is part of every comprehensive history. This review includes changes in the patient’s respiratory, neurologic, cardiac, endocrine, psychiatric, gastrointestinal, urogenital, cutaneous skin, or musculoskeletal systems. The otolaryngologist often may derive more insight into the patient’s problem by inquiring about constitutional changes such as weight loss or gain, fatigue, heat or cold intolerance, rashes, and the like (Box 8-1).

Box 8-1

History

Introduce yourself
Review:

Questionnaire
Medical records
Radiographic imaging
Laboratory values
Pathology specimens

Inquire about chief complaints:

Location
Duration
Characteristics
Medical history
Surgical history
Allergies
Medications

Risk factors:

Tobacco, alcohol
Social history
Family history

Review of systems:

Respiratory
Neurologic
Cardiac
Endocrine
Psychiatric
Gastrointestinal
Urogenital
Skin
Musculoskeletal

Physical Examination

The otolaryngologist must develop an approach to the head and neck examination that allows the patient to feel comfortable while the physician performs a complete and comprehensive evaluation. Many of the techniques used by the otolaryngologist, such as fiberoptic nasopharyngolaryngoscopy, may leave a patient feeling alienated if not done correctly. Thus, it is essential to establish a rapport with a patient before proceeding with the examination.

A word of caution is necessary. The head and neck examination should only be done with the examiner wearing gloves and, in some instances, protective eye covering. Universal precautions are mandatory in today’s practice of medicine. This has the added benefit of showing the patient that the examiner is concerned about not transmitting any diseases, which builds trust between the patient and physician.

General Appearance

Much information can be obtained by first assessing the general behavior and appearance of the patient. For instance, the patient’s affect may suggest possible depression, anxiety, or even alcoholic intoxication. Psychotic behavior in the office may be a result of many factors but may indicate profound hypothyroidism in head and neck cancer patients. Astute observation of the patient’s appearance is equally important. Tar-stained fingernails, teeth, or moustache are harbingers for heavy tobacco consumption. Even the gait of patients as they enter or leave the office may reveal information. Neurologic impairments, especially involving the cerebellum, may affect the patient’s ability to navigate the room.

Facies

After assessing the patient’s overall appearance, the face should be analyzed for facial asymmetry by positioning the head squarely in front of the examiner. For instance, in patients considering facial plastic surgery, a hemifacial microsomia may affect the final outcome, which should be discussed before the operation. In addition, a paretic facial nerve always is a serious finding that can be detected by observing the tone of the underlying facial musculature and overlying facial skin. Facial wrinkles are more prominent when the facial nerve is functioning. For patients recovering from facial nerve paralysis, the American Academy of Otolaryngology–Head and Neck Surgery (AAO-HNS) Facial Nerve Grading System is a respected standard for reporting gradations of nerve function (Table 8-1).

Table 8-1 AAO-HNS Facial Nerve Grading System

Grade Facial Movement  
I Normal Normal facial function at all times
II Mild dysfunction Forehead: moderate-to-good function
Eye: complete closure
Mouth: slight asymmetry
III Moderate dysfunction Forehead: slight-to-moderate movement
Eye: complete closure with effort
Mouth: slightly weak with maximum effort
IV Moderately severe dysfunction Forehead: none
Eye: incomplete closure
Mouth: asymmetrical with maximum effort
V Severe dysfunction Forehead: none
Eye: incomplete closure
Mouth: slight movement
VI Total paralysis No movement

Facial Skeleton

The facial skeleton then should be carefully palpated for bony deformities. This is especially true in patients with recent facial trauma. The periorbital rims may be irregular as a result of fractures involving the zygomatic arches or orbital floor. The dorsum of the nose may be displaced as a result of a comminuted nasal fracture. After evaluation of the facial skeleton, the regions overlying the paranasal sinuses may be firmly palpated or tapped for tenderness, which may be present during an episode of sinusitis.

Evaluation of the temporomandibular joint (TMJ) is convenient to perform at this point in the examination. By having the examiner place three fingers over the TMJ region, which is anterior to the external auditory canal, anteromedial dislocation (caused by the action of the lateral pterygoid muscle) or clicking of the joint can be ascertained. The patient should open and close the jaw to assist in evaluating this synovial joint.

Parotid

Masses in the parotid may be benign or malignant neoplasms of the parotid, cysts, inflammatory masses, or lymph node metastasis from other areas. The tail of the parotid extends to the region lateral and inferior to the angle of the mandible. This is a common site for parotid masses to reside. The parotid-preauricular and retroauricular lymph nodes also should be systematically assessed in every patient. By facing the patient and placing both hands behind the ears before palpating the preauricular nodes, the often-neglected retroauricular nodes will not be missed.

Skin

Skin covering the face and neck should be examined, and suspicious lesions should be noted. The external auricles often receive sun exposure and are at risk for developing the skin malignancies such as basal cell and squamous cell carcinomas. The scalp should be examined for hidden skin lesions, such as melanoma, basal cell carcinoma, or squamous cell carcinoma. All moles should be inspected for irregular borders, heterogeneous color, ulcerations, and satellite lesions.

Neck

The neck, an integral part of the complete otolaryngology examination, is best approached by palpating it while visualizing the underlying structures (Fig. 8-1). The midline structures such as the trachea and larynx can be easily located and then palpated for deviation or crepitus. If there is a thyroid cartilage fracture, tenderness and crepitus may be present. In thick, short necks, the “signet ring” cricoid cartilage is a good landmark to use for orientation. The hyoid bone can be inspected and palpated by gently rocking it back and forth.

image

Figure 8-1. Basic anatomy of the anterior neck. Visualize structures while performing neck examination.

Thyroid Gland

Traveling more inferior in the neck, the thyroid gland, which resides below the cricoid cartilage, should be examined by standing behind the patient and placing both hands on the paratracheal area near the cricoid cartilage. Having the patient swallow or drink a sip of water often helps better delineate the thyroid lobes by having the trachea rise and fall. Pressing firmly in one tracheal groove allows the contents of the other side to be more easily distinguished by gentle palpation. Nodules or cystic structures should be carefully noted and evaluated, often by fine-needle aspiration. Adjacent adenopathy also should be carefully assessed.

Adenopathy

After assessing the thyroid gland, palpation of the supraclavicular area—from the paratracheal grooves posteriorly to the sternocleidomastoid muscle to the trapezius muscle—will help detect masses or enlarged lymph nodes, which are worrisome for metastasis from sources such as the abdomen, breast, or lung. Proceeding more superiorly, the area inferior to the angle of the mandible houses the carotid arteries and often has many lymph nodes, either “shoddy” and indistinct or firm. Palpable nodes always should be noted and may need evaluation with either fine-needle aspiration or radiologic imaging when observation is not appropriate. The carotid artery, often mistaken for a prominent node, can be assessed for the presence of bruits. The entire jugulodigastric chain of lymph nodes merits careful inspection by outlining the sternocleidomastoid muscle and palpating the soft tissue anterior and posterior to it. The submandibular and submental regions are palpated by determining the outline of the glands and any masses present. It often is difficult to distinguish masses from the normal architecture of the submandibular gland. Therefore, bimanual palpation of this area using a gloved finger in the floor of the mouth is helpful.

Triangles of the Neck

Most physicians find it helpful to define the neck in terms of triangles when communicating the location of physical findings (Fig. 8-2). The sternocleidomastoid muscle divides the neck into a posterior triangle—whose boundaries are the trapezius, clavicle, and sternocleidomastoid muscles—and an anterior triangle—bordered by the sternohyoid, digastric, and sternocleidomastoid muscles. These triangles are further divided into smaller triangles. The posterior triangle houses the supraclavicular and the occipital triangles. The anterior triangle then may be divided into the submandibular, carotid, and muscular triangles.

image

Figure 8-2. Triangles of the neck. The anterior triangle is divided from the posterior triangle by the sternocleidomastoid muscle.

Lymph Node Regions

Another classification system for neck masses, endorsed by the American Head and Neck Society and the AAO-HNS, uses radiographic landmarks to define six levels to depict the location of adenopathy (Fig. 8-3). Level I is defined by the body of the mandible, anterior belly of the contralateral digastric muscle, and the stylohyoid muscle. Level IA contains the submental nodes, and level IB consists of the submandibular nodes. They are separated by the anterior belly of the digastric muscle.

image

Figure 8-3. Lymph node regions of the neck. See text for details.

The upper third of the jugulodigastric chain is level II, whereas the middle and lower third represent levels III and IV, respectively. More specifically, the jugulodigastric lymph nodes from the skull base to the inferior border of the hyoid bone are located in level II. Sublevel IIA nodes are located medial to the plane defined by the spinal accessory nerve and sublevel IIB nodes are lateral to the nerve.

Level III extends from the inferior border of the hyoid bone to the inferior border of the cricoid cartilage, and level IV includes the lymph nodes located from the inferior border of the cricoid to the superior border of the clavicle. For levels III and IV, the anterior boundary is the lateral border of the sternohyoid muscle and the posterior limit is the lateral border of the sternocleidomastoid muscle.

Level V is the posterior triangle, which includes the spinal accessory and supraclavicular nodes, and encompasses the nodes from the lateral border of the sternocleidomastoid muscle to the anterior border of the trapezium muscle. Sublevel VA (spinal accessory nodes) is separated from sublevel VB (transverse cervical and supraclavicular nodes) by a plane extending from the inferior border of the cricoid cartilage. Of note, the Virchow node is not in the VB region but is located in level IV.

The pretracheal, paratracheal, precricoid (Delphian), and perithyroidal nodes are contained in level VI, which extends from the hyoid bone to the suprasternal region. The lateral borders are the common carotid arteries.

Although not part of this classification system, the parotid-preauricular, retroauricular, and suboccipital regions are commonly designated as the P, R, and S regions.

Ears

Auricles

The postauricular region, which is frequently overlooked, often has many hidden physical findings. For instance, well-healed surgical incisions signify that previous otologic procedures have been performed. In children, the postauricular mastoid area may harbor important clues that mastoiditis with a subperiosteal abscess has developed. Finally, in patients with head trauma, postauricular ecchymosis (or Battle’s sign) suggests that a temporal bone fracture may have occurred.

The area anterior to the pinna, at the root of the helix, may have preauricular pits or sinuses, which may become infected. The external auricles also may show abnormalities or congenital malformations, including canal atresia, accessory auricles, microtia, and prominent protruding “bat ears.” The outer ears may have edema with weeping, crusting otorrhea, which may signify an infection. Psoriasis of the auricle or external auditory canal with its attendant flaking, dry skin, and edema is another common finding.

Careful examination of the auricles may reveal conditions that require prompt management. For instance, an auricular hematoma—with a hematoma separating the perichondrium from the underlying anterior auricular cartilage—will present as a swollen auricle with distortion of the normal external anatomy. If not surgically drained, a deformed “cauliflower ear” may result. Another important diagnosis is that of carcinoma of the auricle. Because early diagnosis is important, all suspicious lesions or masses should be judiciously biopsied or cultured. A maculopapular rash on the auricle and the external auditory canal in patients with facial nerve paralysis most likely is a result of herpes zoster oticus or Ramsay-Hunt syndrome. Finally, an erythematous painful pinna may represent many diseases, such as perichondritis, relapsing polychondritis, Wegener’s granulomatosis, or chronic discoid lupus erythematosus. Metabolic disorders also may have manifestations that affect the auricles. Patients with gout may have tophus on the pinna that exudes a chalky white substance if squeezed. Ochronosis is an inherited disorder of homogentisic acid that will cause the cartilage of the auricles to blacken. These examples of various diseases and syndromes illustrate the importance of routinely examining the auricles.

External Auditory Canal

The outer third (approximately 11 mm) of the auditory canal is cartilaginous. The adnexa of the skin contain many sebaceous and apocrine glands that produce cerumen. Hair follicles also are present. The inner two thirds (approximately 24 mm) of the canal is osseous and has only a thin layer of skin overlying the bone. Cerumen is commonly found accumulating in the canal, often obstructing it. When removing cerumen, remember two points. The canal is well supplied with sensory fibers: first, CN V3, the auricular branch of CN X, C3, and CN VII. Second, the canal curves in an S-shape toward the nose. To visualize the ear canal, gently grasp the pinna and elevate it upward and backward. This will open the external auditory canal and allow atraumatic insertion of the otoscopic speculum. Cerumen impaction may be removed with many techniques, such as careful curetting, gentle suctioning, or irrigation with warm water.

Otitis externa, or “swimmer’s ear,” is a painful condition with an edematous, often weeping external canal. If severe, the entire canal may be so edematous and inflamed that it closes, making inspection of the tympanic membrane difficult. Gently tugging on the auricle is painful for many patients. The periauricular lymph nodes may be tender and enlarged. If the patient is immunocompromised or diabetic, the canal should be carefully inspected for the presence of granulation tissue at the junction of the cartilaginous and bony junction. This may signify that a malignant otitis externa is present, which, as an osteomyelitis of the temporal bone, requires aggressive management, including prompt intravenous antibiotics.

In older patients, atrophy of the external auditory canal skin is frequently seen and may be associated with psoriasis or eczema of the canal. If patients attempt to soothe an itch with foreign objects such as keys, hair pins, or cotton-tipped swabs, scabs or areas of ecchymosis may be present in the posterior canal wall.

Children are the most likely patients to insert foreign materials into the ear canal. Although most objects lodge lateral to the narrowest part of the canal, the isthmus, some are found in the anterior recess by the tympanic membrane. This makes it especially difficult for the physician to visualize with an otoscope, so patients should turn their head for this area to be viewed. In adults, cotton plugs are commonly lodged and often are impacted against the tympanic membrane. In patients of all ages, insects may find their way into the canal. An operating microscope allows excellent visualization and enables the physician to use both hands to manipulate the instruments needed to remove the object.

Otorrhea is commonly seen in the external auditory canal. The characteristics of the aural discharge may reveal the etiology of the otorrhea. For instance, mucoid drainage is associated with a middle ear chronic suppurative otitis media because only the middle ear has mucus glands. In these patients, a tympanic membrane perforation should be present to allow the mucoid otorrhea to escape. Foul-smelling otorrhea may be caused by chronic suppurative otitis media with a cholesteatoma. Bloody, mucopurulent otorrhea frequently is seen in patients with acute otitis media, trauma, or carcinoma of the ear. Otorrhea with a watery component may signify a cerebrospinal fluid leak or eczema of the canal. Black spores in the otorrhea may be present in a fungal otitis externa caused by Aspergillus species. Gentle suctioning is used to thoroughly clean and inspect the canal.

In patients with head trauma, a temporal bone fracture is important to recognize. Bloody otorrhea in conjunction with an external canal laceration or hemotympanum is a very serious finding. Longitudinal fractures often involve the external canal. Because longitudinal fractures may be bilateral, careful inspection of both canals is essential.

Tympanic Membrane

To view the tympanic membrane, the correct otoscope speculum size is used to allow a seal of the ear canal. With pressure from the pneumatic bulb, the tympanic membrane will move back and forth if the middle ear space is well aerated. Perforations and middle ear effusions are common causes for nonmobile tympanic membranes.

The tympanic membrane is oval, not round, and has a depressed central part called the umbo, wherein the handle of the malleus attaches to the membrane. The lateral process of the malleus is located in the superior anterior region and is seen as a prominent bony point in atelectatic membranes. Superior to this process is the pars flaccida, wherein the tympanic membrane lacks the radial and circular fibers present in the pars tensa, which is the remainder of the ear drum. This superior flaccid area is critical to examine carefully because retraction pockets may develop here, which may develop into cholesteatomas. In congenital cholesteatomas, often diagnosed in young children, the tympanic membrane is intact, and a white mass is seen in the anterior superior quadrant. Acquired cholesteatomas in adults are different in that they often are in the posterior superior quadrant and are associated with retraction pockets, chronic otitis media with purulent otorrhea, and tympanic membrane perforations.

To assess the middle ear for effusions, use the tympanic membrane as a window that allows a view of the middle ear structures (Fig. 8-4). Effusions may be clear (serous), cloudy with infection present, or bloody. When the patient performs a Valsalva maneuver, actual bubbles may form in the effusion.

image

Figure 8-4. The tympanic membrane.

Hearing Assessment

Tuning fork tests, usually done with a 512-Hz fork, allow the otolaryngologist to distinguish between sensorineural and conductive hearing loss (Table 8-2). They also may be used to confirm the audiogram, which may give spurious results because of poor-fitting earphones or variations in equipment or personnel. All tests should be conducted in a quiet room without background noise. Furthermore, one should ensure that the external auditory canal is not blocked with cerumen.

Table 8-2 Tuning Fork Testing

image

The Weber test is performed by placing the vibrating tuning fork in the center of the patient’s forehead or at the bridge of the nose. If the patient has difficulty with these locations, the mandible or front teeth may be used; however, the patient then should tightly clench his or her teeth. The patient then is asked if the sound is louder in one ear or is heard midline. The sound waves should be transmitted equally well to both ears through the skull bone. A unilateral sensorineural hearing loss causes the sound to lateralize to the ear with the better cochlear function. However, a unilateral conductive hearing loss causes the Weber test to lateralize to the side with the conductive loss because the cochlea are intact bilaterally and because bone conduction causes the sound to be better heard in the ear with the conductive loss (because there is less background noise detected through air conduction). Interestingly, a midline Weber result is referred to as “negative.” “Weber right” and “Weber left” refer to the direction to which the sound lateralized.

To compare air conduction with bone conduction, perform the Rinne test. The 512-Hz tuning fork is placed by the ear canal and then on the mastoid process. The patient determines whether the sound is louder when the tuning fork is by the canal (air conduction) or on the mastoid bone (bone conduction). A “positive test” result is air conduction louder than bone conduction. A conductive hearing loss will make bone conduction louder than air conduction, and this is called “Rinne negative.” When the air and bone conduction are equal, it is called “Rinne equal.”

The Schwabach test compares the patient’s hearing with the examiner’s hearing and uses multiple tuning forks such as the 256-, 512-, 1024-, and 2048-Hz forks. The stem of the vibrating tuning fork is placed on the mastoid process of the patient and then on the mastoid of the physician. This is done, alternating between the two participants, until one can no longer hear the tuning fork. This test assumes that the examiner has normal hearing. If the patient hears the sound as long as the physician, the result is “Schwabach normal.” If the patient hears the sound longer than the physician, it is called “Schwabach prolonged.” This may indicate a conductive hearing loss for the patient. If the patient hears the sound for less time than the physician, it is called “Schwabach shortened.” This is consistent with sensorineural hearing loss for the patient.

Oral Cavity

The boundaries of the oral cavity extend from the skin-vermillion junction of the lips, hard palate, anterior two thirds of the tongue, buccal membranes, upper- and lower-alveolar ridge, and retromolar trigone to the floor of the mouth. This region may be best seen by having the otolaryngologist use a well-directed headlight and a tongue depressor in each gloved hand. The lips should be carefully inspected. Remember that lip squamous cell carcinoma is more common on the lower lip. The commissures may have fissuring, which is seen in angular stomatitis or cheilosis. When the fissures and cracking are present on the mid-portion of the lips, this may be cheilitis.

The occlusion of the teeth and the general condition of the alveolar ridges, including the gums and teeth, should be noted. The tongue, especially the lateral surfaces where carcinomas are most common, should be inspected for induration or ulcerative lesions. Gently grabbing the anterior tongue with a gauze sponge allows the examiner to move the anterior tongue from side to side. By having the patient lift the tongue toward the hard palate, the floor of mouth and Wharton’s ducts (associated with submandibular glands) can be viewed. Pooling of carcinogens in the saliva on the floor of the mouth has been postulated to cause this area to have a high incidence of carcinoma. The examiner should palpate the floor of the mouth using a bimanual approach with one gloved hand in the mouth.

The buccal membranes should be inspected for white plaques that may represent oral thrush, which easily scrapes off with a tongue blade, or leukoplakia, which cannot be removed. More worrisome for a precancerous condition is erythroplakia; therefore all red lesions and most white lesions should be judiciously biopsied for cancer or carcinoma in situ. While examining the buccal membranes, one should note the location of the parotid duct, or Stenson’s duct, as it opens near the second upper molar. Small yellow spots in the buccal mucosa are sebaceous glands, commonly referred to as Fordyce spots, and are not abnormal. Aphthous ulcers, or the common canker sore, are painful white ulcers that can be on any part of the mucosa but are commonly present on the buccal membrane.

The hard palate may have a bony outgrowth known as a torus palatinus. These midline bony deformities are benign and should not be biopsied, although growths that are not in the midline should be more carefully evaluated as possible cancerous lesions.

Oropharynx

The oropharynx includes the posterior third of the tongue, anterior and posterior tonsillar pillars, the soft palate, the lateral and posterior pharyngeal wall, the soft palate, and the vallecula (Fig. 8-5). It is best visualized using a head lamp and two tongue depressors. A dental mirror is beneficial in viewing the vallecula and the posterior pharyngeal wall, which often are obscured. Using a gloved finger to examine the base of tongue or tonsil may reveal indurated areas that may be appropriate for biopsy for neoplasm. The patient should be aware of the possibility that gagging may ensue when this is done. In patients with especially strong gag reflexes, a fiberoptic examination may be necessary to fully assess the base of tongue, posterior pharyngeal wall, and vallecula. By carefully passing the flexible fiberoptic endoscope through the anesthetized nose, the interaction of the soft palate and tongue base during swallowing also may be viewed. The uvula should be inspected because a bifid structure may signify a submucosal cleft palate. In addition, an inflamed large uvula may mean the uvula has been traumatized during the night if the patient snores heavily. Small carcinomas or papilloma lesions also may be present, so careful palpation may be indicated.

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Figure 8-5. The oropharynx, which includes the posterior third of the tongue, soft palate, tonsillar pillars (anterior and posterior), lateral and posterior pharyngeal wall, and vallecula.

The size of the tonsils usually is denoted as 1+, 2+, 3+, or 4+ (for “kissing tonsils” that meet in the midline). The tonsils and the base of tongue may contribute to upper-airway obstruction, especially if the soft palate and uvula extend posteriorly. Therefore the oropharyngeal aperture should be carefully assessed in each patient. Tonsillitis, caused by either bacterial or viral sources such as group A streptococci or mononucleosis, often presents with an exudate covering the cryptic tonsils. Tonsilliths are a common cause for a foreign body sensation in the back of the throat. These yellow or white concretions in the tonsillar crypts are not caused by food trapping or infection, but they often cause the patient to have halitosis and may be removed with a cotton-tipped swab.

Larynx and Hypopharynx

The larynx often is subdivided into the supraglottis, glottis, and subglottis. The supraglottic area includes the epiglottis, the aryepiglottic folds, the false vocal cords, and the ventricles. The glottis comprises the inferior floor of the ventricle, the true vocal folds, and the arytenoids. The subglottis region generally is considered to begin 5 to 10 mm below the free edge of the true vocal fold and to extend to the inferior margin of the cricoid cartilage, although this is somewhat controversial (Fig. 8-6).

image

Figure 8-6. The larynx.

The hypopharynx can be challenging to understand. It extends from the superior edge of the hyoid bone to the inferior aspect of the cricoid cartilage by the cricopharyngeus muscle. It connects the oropharynx with the esophagus. This region comprises three areas: the pyriform sinuses, posterior hypopharyngeal wall, and the postcricoid area. This area, rich in lymphatics, may harbor tumors that often are detected only in an advanced stage. Thus early detection of these relatively “silent” carcinomas is important and should not be missed.

The examiner should not only detect anatomic abnormalities but also should observe how the larynx and hypopharynx are functioning to allow the patient to have adequate airway, vocalization, and swallow function. To survey the larynx for lesions and assess the true vocal fold function is not enough. For example, the patient with a normal-appearing larynx may have decreased laryngeal sensation with resultant aspiration and may need further diagnostic and therapeutic evaluation. Therefore important information can be obtained when the physician carefully assesses the anatomic and functional aspects of this complex area.

Correct positioning of patients increases their comfort while maximizing the examiner’s view of the larynx. The legs should be uncrossed and placed firmly on the footrest. The back should be straight with the hips planted firmly against the chair. Patients, while leaning slightly forward from the waist, should place their chin upward so that the examiner’s light source is sufficiently illuminating the oropharynx. After discussing the examination procedure with the patient, the patient’s tongue is pulled forward by the examiner, who uses a gauze sponge between the thumb and index finger. This allows the physician’s long middle finger to retract the patient’s upper lip superiorly. A warm dental mirror (to prevent fogging) is placed in the oropharynx and elevates the uvula and soft palate to view the larynx (Fig. 8-7). The patient with a strong gag reflex may benefit from a small spray of local anesthetic to help suppress the reflex.

image

Figure 8-7. The laryngeal examination.

Some maneuvers allow better visualization of the larynx and its related structures. Panting, quiet breathing, and phonating with a high-pitched E aid in assessing true vocal fold function.

The epiglottis should be crisp and whitish. An erythematous, edematous epiglottis may signify epiglottitis, a serious infection or inflammation that mandates consideration of airway control. The petiole of the epiglottis is a peaked structure on the laryngeal surface of the epiglottis above the anterior commissure of the true vocal folds. It may be confused for a cyst or mass but is a normal prominence. Irregular mucosal lesions may be carcinomas and require further evaluation.

In the posterior glottis, movement of the arytenoids allows determination of true vocal fold mobility. The interarytenoid mucosa may be edematous or erythematous, sometimes representing gastroesophageal reflux laryngitis. The mucosa over the arytenoids may be erythematous as a result of rheumatoid arthritis or as a result of recent intubation trauma. Posterior glottic webs or scars also may be present.

The true vocal folds should have translucent white, crisp borders that meet each other. Edema of the folds that extends for the entire fold length often is caused by Reinke’s edema, seen in tobacco users. Actual polypoid degeneration of the vocal cord with obstructing polyps may occasionally be seen in patients and may be a result of tobacco use or hypothyroidism. Ulcerative or exophytic lesions deserve further investigation, usually requiring operative direct laryngoscopy. True vocal fold paralysis and subtle gaps present between the folds during cord adduction should be noted.

During abduction of the cords, the subglottic area may be viewed. A prominent cricoid cartilage, seen inferiorly to the anterior commissure, may be mistaken for a subglottic stenosis. It is difficult to fully inspect the subglottic area in the office setting. Any concerns about subglottic inflammatory swelling, masses, or stenosis should be addressed in an operative setting or through radiographic imaging.

Flexible Endoscopy

Perhaps the best technique to evaluate the function of the larynx uses the flexible fiberoptic nasopharyngolaryngoscope. In conjunction with a strong light source, this allows a more complete evaluation of the structures of the larynx than a mirror examination.

A topical decongestant and anesthetic spray usually is applied to the nares. The patient is asked to gently sniff these nose sprays. Commonly used as topical anesthetics are 1% Pontocaine and 2% lidocaine. Another way to administer anesthesia is to carefully apply a viscous 2% lidocaine solution to the nares with a cotton-tipped applicator. It is important to allow time for these topical agents to anesthetize the nasal mucosa. While the physician is waiting, the scope can be prepared. The focus ring is used to get the brightest possible image. Often a small amount of residue is at the end of the fiberoptic scope. This can be carefully removed using either a pencil eraser or an alcohol swab. If the image is unclear before the scope is put in the nose, the image will be inadequate when the fiberoptic scope has been passed through the nares. Once the best possible focus has been obtained, before passing the scope through the nares, a small amount of water-soluble lubricant should be applied approximately 1 cm from the tip of the scope. This is to prevent breakage of the fiberoptic component of the scope while it is passed through the nose.

The laryngoscope then is gently passed along the floor of the nose and, with the instrument tip held above the epiglottis, the larynx may be viewed. Pooling of secretions in the pyriform sinuses is abnormal and is common in patients with decreased laryngeal sensation, neurologic impairment, or tumors. Saliva freely flowing in and out of the true cords is another indication of decreased laryngeal function. In some patients, having patients inhale and hold their breath often aids in viewing the pyriform sinuses. Asking the patient to cough and swallow and then viewing the residual saliva or phlegm also is helpful. The flexible fiberoptic examination enables the patient to freely phonate, unlike with the mirror examination. The true vocal folds may be assessed by moving the instrument tip into the laryngeal vestibule for closer inspection.

Rigid telescopic examination with 70-, 90-, and 110-degree telescopes is performed in a similar fashion to the mirror examination. It permits photographic documentation of the laryngeal examination. In patients with trismus, this is better tolerated than the mirror examination, and a minimal amount of local anesthetic usually is necessary.

Nose

Anterior rhinoscopy, using a head lamp and nasal speculum, allows assessment of the nasal septum and inferior turbinates. The speculum should be directed laterally to avoid touching the sensitive septum with the metal edges. The point wherein numerous small branches of the external and internal carotid arteries meet, or Kiesselbach’s plexus, is the most common site for epistaxis; prominent vessels in this area should be noted. Anterior septal deviations and bony spurs often are evident. The characteristics of the mucosa of the inferior turbinate may range from the boggy, edematous, pale mucosa seen in those with allergic rhinitis to the erythematous, edematous mucosa seen in those with sinusitis.

Nasal endoscopy using rigid endoscopes allows thorough examination of even the most posterior portions of the nasal cavity. After applying a local anesthetic to the nares (either lidocaine or Pontocaine spray or topical 4% cocaine), the rigid 0-degree endoscope may be passed into the nose along the floor of the nasal vault. The septum, inferior turbinate, and eustachian tube orifices in the nasopharynx may be seen this way. Often at this time it is necessary to spray a decongestant to shrink the nasal mucosa. It is helpful to attempt to view the nasal anatomy in both the native state and after the decongestant so that the effect of the decongestant may be seen. After inspecting both sides, the endoscope is placed above the inferior turbinate to view the middle turbinate. Accessory ostia from the maxillary sinus often are present, especially in patients with chronic sinusitis. These openings into the lateral nasal wall often are mistaken for the true maxillary ostium.

Nasopharynx

The nasopharynx extends from the skull base to the soft palate. This is a challenging area to examine, but with the available technology, there are many ways to approach this region. The technique used often depends on the anatomy of the patient. In the patient with a high posterior soft palate and small tongue base, an otolaryngologist may use a small dental mirror and a head lamp to visualize the nasopharynx. By having the patient sit upright in the chair, the physician may firmly pull the tongue forward while opening the mouth to place the mirror just posterior to the soft palate. In a manner analogous to that used to view the larynx with a mirror, the structures in the nasopharynx are seen when the mirror is oriented upward.

Another method uses a fiberoptic nasopharyngoscope, which allows excellent visualization of this area. After anesthetizing the nares with either topical cocaine (on pledgets) or applying lidocaine spray, many otolaryngologists spray the nares with a decongestant. The flexible fiberoptic scope then is gently passed along the floor of the nostril beneath the inferior turbinate. The eustachian tube orifice, torus tubarius, and fossa of Rosenmüller should be inspected on each side. This may be accomplished by using the hand control to turn the tip of the scope from side to side. The midline also should be inspected for any masses, ulcerations, or bleeding areas. Rigid endoscopes offer good visualization also, although the ability to view both sides of the nasopharynx often means passing the endoscope through each nostril. The endoscopes have various angles (e.g., 70, 90, and 110 degrees).

Arguably, the best view may be obtained using a 90-degree rigid scope in the oropharynx. By advancing the rigid scope through the mouth and by placing the beveled edge posterior to the soft palate, the nasopharynx may be seen in its entirety. Both sides of the nasopharynx may be compared for symmetry using this technique.

Whereas children have adenoid tissue present, adults should not have much adenoid tissue remaining in this area. Thus adenoid tissue should not be a cause of nasal or eustachian tube obstruction in adults. One possible exception is in patients with HIV infections, who may manifest adenoid hypertrophy as part of their disease. Nonetheless, adults with an otitis media, especially unilateral in nature, should have their nasopharynx inspected for possible nasopharyngeal masses. If present, it is important to diagnose nasopharyngeal carcinomas, which are most common lateral to the eustachian tube orifice in the fossa of Rosenmüller. In young male patients, nasopharyngeal angiofibromas are locally aggressive but histologically benign masses that are most commonly present in the posterior choana or nasopharynx. These masses should not be missed. Another malignancy to consider is non-Hodgkin’s lymphoma. Cysts in the superior portion of the nasopharynx may represent a benign Tornwaldt cyst or a malignant craniopharyngioma.

Neurologic Examination

Table 8-3 outlines the basics of a neurologic examination appropriate for most head and neck patients. Certainly patients presenting with vertigo or dysequilibrium require a highly specialized neurologic examination, but that is beyond the scope of this chapter. Much valuable clinical information can be obtained with an evaluation of the cranial nerves.

Table 8-3 Neurologic Examination

Cranial Nerves Tests
I Sense of smell to several substances
Do not use ammonia (common chemical sense caused by CN V stimulation)
II Visual acuity
Visual fields
Inspect optic fundi
III Extraocular movements in six fields of gaze
IV Pupillary reaction to light
V Palpate temporal and masseter muscles
Patient should clench teeth
Test forehead, cheeks, jaw for pain, temperature, and light (cotton) touch
Corneal reflex (blinking in response to cotton touching the cornea)
VI Near reaction to light
Ptosis of upper eyelids
VII Symmetry of face in repose
Raise eyebrows, frown, close eyes tightly, smile, puff out cheeks
VIII Auditory—tuning fork tests for hearing
Vestibular—nystagmus on lateral gaze; Hallpike-Dix test; head shaking; caloric testing; Frenzel lenses
IX, X Hoarseness
True vocal cord mobility
Gag reflex (CN IX or X)
Movement of soft palate and pharynx
XI Shrug shoulders against examiner’s hand (trapezius muscle)
Turn head against examiner’s hand (sternocleidomastoid muscle)
XII Stick tongue out
Tongue deviates toward side of lesion
Tongue atrophy, fasciculations

CN, cranial nerve.

Preoperative Evaluation

The patient presenting with an otolaryngologic disease process that requires surgical management must be evaluated by both general and specialty-specific criteria. Additional testing, prophylactic measures, and behavioral modification before surgery can then be implemented to maximize the surgical outcome. In addition, the patient’s prior anesthetic record provides invaluable insight into issues such as airway management and overall tolerance of general, regional, local, or neuroleptic anesthesia. A social history can often be extremely beneficial as well, providing a means of anticipating postoperative needs and circumventing some prolonged admissions. Any significant issues should be raised with the departmental or hospital social worker, preferably before surgery. Last, it is important to elicit a detailed list of current medications and allergies.

In uncomplicated cases, the history and physical examination are followed by routine screening tests. Blood is drawn for a complete blood count (CBC), serum electrolytes, blood urea nitrogen (BUN), creatinine, glucose, and a clotting profile to rule out a wide range of possible occult abnormalities. In patients older than 40 years of age or in those with pertinent past medical histories, chest radiography and electrocardiography (ECG) are performed. Additionally, women of childbearing age should undergo pregnancy testing.

When the need arises, consultation with appropriate specialties should be sought quickly. The consultant should be clearly informed about the nature of the proposed procedure and should be asked to comment specifically on the relative safety of performing the procedure with respect to concomitant disease processes. In cases complicated by many medical problems or those in which the establishment of a safe airway is an issue, close consultation with the anesthesia team is advised to avoid undue delay, cancellation of the procedure, or an undesirable outcome.

It is imperative to have copies of all laboratory results, radiographs, and pertinent tests available for review before surgery. Additional studies should be ordered by the surgeon as deemed necessary.

Consent

Although a detailed discussion of the legal ramifications of informed consent is beyond the scope of this chapter, the ethical ideal deserves consideration. An integral part of the preoperative process is the physician’s thorough and candid explanation to the patient of the procedure, its risks, and the probable outcomes. The relationship that develops between the surgeon and patient at this time often does more to prevent litigation if an unfortunate circumstance occurs than any legal document detailing the risks and benefits. The potential risks and outcomes that would sway a patient’s decision to undergo the procedure must be discussed with the patient and documented in the chart.

Allergy

The surgeon must guard against anaphylactic reactions in all patients. The crux of this process is to have the patient identify any untoward reactions to medications, foods, or other materials. In most instances, many of the drug “reactions” described by patients do not represent true allergic phenomena. Instead, they are simply drug side effects. Nonetheless, these reactions require thorough documentation and avoidance of the allergens in the perioperative period.

Anaphylaxis results in the release of potent inflammatory agents, vasoactive substances, and proteases, all of which bring about the shock reaction. Urticaria, profound hypotension, tachycardia, bronchoconstriction, and airway-compromising edema of the mucosal surfaces of the upper aerodigestive tract may develop. Even in intubated patients, rapid oxygen desaturation is often a prominent feature. As the reaction progresses, cardiac arrest can ensue despite maximal resuscitative efforts. Given the potential morbidity and mortality of anaphylactic reactions, the otolaryngologist must identify all of a patient’s allergens in the preoperative phase.

The incidence of serious adverse reactions to penicillin is about 1%. It is widely believed that there is a 10% to 15% chance that patients who manifest these reactions also react adversely to cephalosporins. Based on my empirical observations, I believe that unless these patients have had a history of significant atopy or penicillin-induced urticaria, mucosal edema, or anaphylaxis, they can be given cephalosporins with relative impunity. Anaphylactic reactions to cephalosporins in true penicillin-allergic patients are probably less than 2%. Moreover, cephalosporins cause their own independent hypersensitivity reactions. The notion of cross-reactivity with penicillin on skin testing seems to stem from data obtained in the 1970s, in which contamination of cephalosporins with penicillin was subsequently proven. Finally, if a serious penicillin allergy is evident, alternative antibiotics such as clindamycin may be substituted for the cephalosporins.

Mucosal absorption of latex protein allergens from the surgeon’s gloves can rapidly incite anaphylactic shock in patients who are highly sensitive to latex. About 7% to 10% of health care workers regularly exposed to latex and 28% to 67% of children with spina bifida demonstrate positive skin tests to latex proteins. Preoperatively, if a patient gives a history suspicious for latex allergy, it should be investigated before surgery. If the allergy is documented, perioperative precautions to avoid latex exposure must be instituted.

Similarly, patients with allergic or adverse reactions to soybean or eggs may react to propofol, a ubiquitous induction agent. Protamine and intravenous contrast agents can potentially provoke hypersensitivity responses in patients with known shellfish or other fish allergies. Although rare, some patients have allergic reactions to ester types of local anesthetics such as cocaine, procaine, and tetracaine.

Finally, if the suspicion of allergy or adverse reaction exists, the best course of action is to avoid use of the potential offending agent altogether during surgery. If this is not feasible for some reason, then the surgeon and anesthesiologist should plan on premedicating the patient with systemic steroids, histamine antagonists, and even bronchodilators. The physicians should then be prepared to deal with the potential worst-case scenario of anaphylactic shock.

Systems

Cardiovascular

Cardiovascular complications are the most common cause of perioperative mortality. Specifically, an almost 50% mortality rate is associated with perioperative myocardial infarction. Meticulous review of the cardiovascular system is of utmost importance in determining a patient’s surgical candidacy, especially those who will require a general anesthetic. Risk factors for a perioperative cardiovascular complication include jugular venous distention, third heart sounds, recent myocardial infarction (MI) (within 6 months), nonsinus heart rhythm, frequent premature ventricular contractions (>5 per minute), age older than 70 years, valvular aortic stenosis, previous vascular or thoracic surgery, and poor overall medical status. Emergency surgery poses an additional risk for cardiovascular complications. In the head and neck oncology patient population, the high incidence of tobacco and alcohol abuse leads to a relatively high incidence of coronary artery disease, cardiomyopathy, and peripheral vascular disease.

The otolaryngologist should obtain a history of previous MIs, angina, angioplasty or bypass surgery, congestive heart failure (CHF) or dyspnea on exertion, hypertension, general exercise tolerance, paroxysmal nocturnal dyspnea, claudication, stroke or transient ischemic attack, syncope, palpitations or other arrhythmias, as well as known anatomic or auscultative cardiac anomalies. The presence or suspicion of coronary artery disease, heart failure, untreated hypertension, or significant peripheral vascular disease should prompt a specific anesthesiology or cardiology consultation before surgery. This evaluation would include an assessment of the electrocardiogram, as well as possible exercise or chemical stress testing, echocardiography, and cardiac catheterization as indicated. The result of this consultation should determine the surgical and anesthetic risk and should optimize the patient’s preoperative cardiovascular status. Furthermore, specific intraoperative and postoperative physiologic (e.g., invasive monitors) and pharmacologic precautionary measures should be delineated, as should the level of postoperative observation.

In general, patients are maintained on their antihypertensive, antianginal, and antiarrhythmic regimens up to the time of surgery. Certain medications such as diuretics and digoxin may be withheld at the discretion of the anesthesiologist or cardiologist. Preoperatively, serum electrolytes and antiarrhythmic levels should be checked and adjusted as necessary. Coagulation studies (prothrombin time [PT]/partial thromboplastin time [PTT]) and platelet quantification are routinely obtained in patients with cardiovascular risk factors because significant bleeding can lead to major perioperative cardiovascular complications. A relatively current chest radiograph is considered essential in this high-risk group.

Preoperatively, the otolaryngologist must be aware of the types of procedures that may have specific cardiovascular ramifications. Patients with prosthetic valves and those with a history of rheumatic fever, endocarditis, congenital heart defects, mitral valve prolapse with regurgitation, or hypertrophic cardiomyopathy should receive prophylactic antibiotics at the time of surgery. Such prophylaxis is especially important during procedures performed on the oral cavity and upper aerodigestive tract. This is also important when dealing with surgical drainage of head and neck infections, in which the risk of hematogenous bacterial seeding is high. For low-risk procedures, intravenous ampicillin—2 g given 30 minutes before surgery, followed by 1 g given 6 hours later—is sufficient prophylaxis. In high-risk procedures, intravenous gentamicin (1.5 mg/kg) and intravenous ampicillin (2 g) are administered 30 minutes before surgery, followed by the same doses of each 8 hours later. Patients with pacemakers or implanted defibrillators and those with mitral valve prolapse without regurgitation do not require endocarditis prophylaxis.

Airway, carotid, and vagus nerve manipulation can induce bradycardia and hypotension. Agents such as lidocaine, epinephrine, and cocaine, which are frequently used in sinonasal surgery, can trigger undesirable cardiovascular events. Injury to the cervical sympathetic chain may precipitate postural hypotension postoperatively. Finally, the surgeon must also be cognizant that a unipolar electrocautery device can reprogram a pacemaker during surgery.

Respiratory

Postoperative pulmonary complications are considered the second most common cause of perioperative mortality. This is not surprising considering the effects of general anesthesia and surgery on pulmonary performance. Atelectasis and ventilation/perfusion mismatch occur secondary to a number of factors, including the use of anesthetic agents and positive pressure ventilation, as well as supine positioning. Anesthetic agents, barbiturates, and opioids tend to diminish the ventilatory response to hypercarbia and hypoxia. Endotracheal intubation bypasses the warming and humidifying effects of the upper airway, leading to impaired ciliary function, thickened secretions, and subsequent decreased resistance to infection. Furthermore, postoperative pain substantially affects a patient’s ability to cough, especially following thoracic or abdominal procedures (e.g., chest myocutaneous flap, gastric pull-up, percutaneous endoscopic gastrostomy, rectus free-flap, iliac crest bone graft). Because of their attenuated respiratory reserve, patients with chronic pulmonary disease are much more likely to suffer postoperative pulmonary complications than are healthy patients. For instance, heavy smokers have a threefold increase in the risk of postoperative pulmonary complications when compared with nonsmokers. Hence it is imperative to identify these patients during the preoperative evaluation.

Specifically, a positive history of asthma, chronic obstructive pulmonary disease, emphysema, tobacco abuse, pneumonia, pulmonary edema, pulmonary fibrosis, or adult respiratory distress syndrome requires heightened attention before surgery. The prior treatment of these lung problems, including the number of hospitalizations and emergency department visits; the use of medications like steroids, antibiotics, and bronchodilators; and the need for intubation or chronic oxygen therapy should be addressed. The otolaryngologist should obtain an estimate of the patient’s dyspnea, exercise limitation, cough, hemoptysis, and sputum production. Factors that exacerbate chronic lung disease must be identified. Once again, it is of paramount importance to investigate the tolerance of previous anesthetics in this high-risk group. Coexisting cardiac and renal disease such as CHF and chronic renal failure also impact heavily on pulmonary function. Pulmonary hypertension and cor pulmonale secondary to obstructive sleep apnea, cystic fibrosis, muscular dystrophy, emphysema, or kyphoscoliosis further complicate anesthetic management. Congenital diseases affecting the lungs such as cystic fibrosis and Kartagener’s syndrome (rare) present the challenge of perioperative clearance of secretions.

On physical examination, the clinician should be attuned to the patient’s body habitus and general appearance. Obesity, kyphoscoliosis, and pregnancy can all predispose to poor ventilation, atelectasis, and hypoxemia. Cachectic patients are more likely to develop postoperative pneumonia. It should be noted that clubbing and cyanosis, although suggestive, are not reliable indicators of chronic pulmonary disease. The patient’s respiratory rate is determined, and the presence of accessory muscle use, nasal flaring, diaphoresis, or stridor should be documented. Auscultation that reveals wheezing, rhonchi, diminished breath sounds, crackles, rales, and altered inspiratory/expiratory time ratios should raise the suspicion of pulmonary compromise.

In patients with pulmonary disease, preoperative posteroanterior and lateral chest radiography is mandatory, because findings often direct modification of the anesthetic technique used during surgery. Arterial blood gas (ABG) testing on room air is also indicated. Patients with an arterial oxygen tension less than 60 mm Hg or an arterial carbon dioxide tension greater than 50 mm Hg are more likely to have postoperative pulmonary complications. Serial ABG determinations can also be used to assess the overall efficacy of preoperative medical and respiratory therapy. As with chest radiography, preoperative ABG levels also provide a baseline for postoperative comparison.

Preoperative pulmonary function tests such as spirometry and flow-volume loops are quite helpful. A quantitative measure of ventilatory function can also be used to assess the efficacy of both preoperative and surgical interventions. Spirometry can be used to differentiate restrictive from obstructive lung disease, as well as to predict perioperative morbidity from pulmonary complications. Generally, a forced expiratory volume in 1 second/forced vital capacity ratio of less than 75% is considered abnormal, whereas a ratio of less than 50% carries a significant risk of perioperative pulmonary complications. Preoperative flow-volume loops can distinguish among fixed (e.g., goiter), variable extrathoracic (e.g., unilateral vocal cord paralysis), and variable intrathoracic (e.g., tracheal mass) airway obstructions.

The preoperative management of otolaryngology patients with significant pulmonary disease is vital and should follow the recommendations of a pulmonologist. Smokers are advised to cease smoking for at least a week before surgery. Chest physiotherapy aimed at increasing lung volumes and clearing secretions is instituted. This includes coughing and deep breathing exercises, incentive spirometry, and chest percussion with postural drainage. It is not advisable to operate on a patient with an acute exacerbation of pulmonary disease or with an acute pulmonary infection. Acute infections should be cleared with antibiotics and chest physiotherapy before elective surgery. Prophylactic antibiotics in noninfected patients are not recommended for fear of selecting out resistant organisms. Finally, the medical regimen, including the use of inhaled beta-adrenergic agonists, cromolyn, and steroids (inhaled or systemic), must be optimized. Serum levels of theophylline, if used, should be therapeutic.

Renal

The preoperative identification and evaluation of renal problems is also imperative. Any significant electrolyte abnormalities uncovered during the routine screening of healthy patients should be corrected preoperatively, and surgery should be delayed if additional medical evaluation is warranted. Preexisting renal disease is a major risk factor for the development of acute tubular necrosis both during and after surgery. Renal failure, whether acute or chronic, influences the types, dosages, and intervals of perioperative drugs and anesthetics. An oliguric or anuric condition requires judicious fluid management, especially in patients with cardiorespiratory compromise. Furthermore, chronic renal failure (CRF) is often associated with anemia, platelet dysfunction, and coagulopathy. Electrolyte abnormalities, particularly hyperkalemia, can lead to arrhythmias, especially in the setting of the chronic metabolic acidosis that often accompanies CRF. Hypertension and accelerated atherosclerosis resulting from CRF are risk factors for developing myocardial ischemia intraoperatively. Blunted sympathetic responses may predispose to hypotensive episodes during administration of anesthesia. The otolaryngologist must also be wary of the potential for injury to demineralized bones during patient positioning. An impaired immune system can contribute to poor wound healing and postoperative infection. Finally, because patients with CRF have often received blood transfusions, they are at increased risk of carrying blood-borne pathogens such as hepatitis B and C.

The possible causes of renal disease, including hypertension, diabetes, nephrolithiasis, glomerulonephritis, polycystic disease, lupus, polyarteritis nodosa, Goodpasture’s or Wegener’s syndrome, trauma, or previous surgical or anesthetic insults, should be elicited. The symptoms of polyuria, polydipsia, fatigue, dyspnea, dysuria, hematuria, oliguria or anuria, and peripheral edema are recorded, as is a complete listing of all medications taken by the patient.

In dialyzed patients, it is important to document the dialysis schedule. A nephrologist should assist with the preoperative evaluation and should optimize the patient’s fluid status and electrolytes before surgery. A nephrologist should also be available to help manage these issues postoperatively, especially when major head and neck, skull-base, or neurotologic surgery—which may require large volumes of fluids or blood transfusions intraoperatively—is planned.

Preoperative testing on patients with significant renal disease routinely includes ECG, chest radiography, electrolytes and chemistry panel, CBC, PT/PTT, platelet counts, and bleeding times. In addition to a nephrologic consultation, patients with significant renal disease should also receive a preoperative anesthesiology consultation, and, if indicated, further evaluation by a cardiologist.

A history of benign prostatic hypertrophy or prostate cancer, with or without surgery, may predict a difficult urinary tract catheterization intraoperatively. Finally, elective surgery should not be performed on patients with acute genitourinary tract infections because the potential for urosepsis can be increased by the transient immunosuppression associated with general anesthesia.

Hepatic Disorders

Preoperative evaluation of patients with suspected or clinically evident liver failure should begin with a history detailing hepatotoxic drug therapy, jaundice, blood transfusion, upper gastrointestinal bleeding, and previous surgery and anesthesia. The physical should include examination for hepatomegaly, splenomegaly, ascites, jaundice, asterixis, and encephalopathy. The list of blood tests is fairly extensive and includes hematocrit, platelet count, bilirubin, electrolytes, creatinine, BUN, serum protein, PT/PTT, serum aminotransferases, alkaline phosphatase, and lactate dehydrogenase. A viral hepatitis screen can be obtained as well. Of note, patients with moderate to severe chronic alcoholic hepatitis may present with relatively normal-appearing liver function tests and coagulation parameters; these patients are at risk for perioperative liver failure.

Cirrhosis and portal hypertension have wide-ranging systemic manifestations. Arterial vasodilation and collateralization leads to decreased peripheral vascular resistance and an increased cardiac output. This hyperdynamic state can occur even in the face of alcoholic cardiomyopathy. The responsiveness of the cardiovascular system to sympathetic discharge and administration of catechols is also reduced, likely secondary to increased serum glucagon levels. Cardiac output can be reduced by the use of propranolol, which has been advocated by some as a treatment for esophageal varices. By decreasing cardiac output, flow through the portal system and the esophageal variceal collaterals is diminished. Additionally, there is likely a selective splanchnic vasoconstriction. Once initiated, beta-blockade cannot be stopped easily because of a significant rebound effect.

Renal sequelae vary with the severity of liver disease from mild sodium retention to acute failure associated with the hepatorenal syndrome. Diuretics given to decrease ascites can often lead to intravascular hypovolemia, azotemia, hyponatremia, and encephalopathy. Fluid management in the perioperative period should be followed closely and dialysis instituted as needed for acute renal failure.

From a hematologic standpoint, patients with cirrhosis often have an increased 2,3-diphosphoglycerate level in their erythrocytes, causing a shift to the right of the oxyhemoglobin dissociation curve. Clinically, this results in a lower oxygen saturation. This situation is further compounded by the frequent finding of anemia. Additionally, significant thrombocytopenia and coagulopathy may be encountered. The preoperative use of appropriate blood products can lead to short-term correction of hematologic abnormalities, but the prognosis in these patients remains poor.

Encephalopathy stems from insufficient hepatic elimination of nitrogenous compounds. Although measurements of BUN and serum ammonia levels are useful, they do not always correlate with the degree of encephalopathy. Treatment includes hemostasis, antibiotics, meticulous fluid management, low-protein diet, and lactulose.

Endocrine Disorders

Thyroid

Symptoms of hyperthyroidism include weight loss, diarrhea, skeletal muscle weakness, warm, moist skin, heat intolerance, and nervousness. Laboratory test results may demonstrate hypercalcemia, thrombocytopenia, and mild anemia. Elderly patients also can present with heart failure, atrial fibrillation, or other dysrhythmias. The term thyroid storm refers to a life-threatening exacerbation of hyperthyroidism that results in severe tachycardia and hypertension.

Treatment of hyperthyroidism attempts to establish a euthyroid state and to ameliorate systemic symptoms. Propylthiouracil inhibits both thyroid hormone synthesis and the peripheral conversion of T4 to T3. Complete clinical response may take up to 8 weeks, during which the dosage may need to be tailored to prevent hypothyroidism. Potassium iodide (Lugol’s solution), which works by inhibiting iodide organification, can be added to the medical regimen. In patients with sympathetic hyperactivity, beta-blockers have been used effectively. Propranolol has the added benefit of decreasing T4-to-T3 conversion. It should not be used in patients with CHF secondary to poor left ventricular function or bronchospasm because it will exacerbate both of these conditions. Ideally, medical therapy should prepare a mildly thyrotoxic patient for surgery within 7 to 14 days. If the need for emergency surgery arises, intravenous propranolol or esmolol can be administered and titrated to keep the heart rate below 90 bpm. Other medications that can be used include reserpine and guanethidine, which deplete catechol stores, and glucocorticoids, which decrease both thyroid hormone secretion and T4-to-T3 conversion. Radioactive iodine also can be used effectively to obliterate thyroid function but should not be given to women of childbearing years.

The symptoms of hypothyroidism result from inadequate circulating levels of T4 and T3 and include lethargy, cognitive impairment, and cold intolerance. Clinical findings may include bradycardia, hypotension, hypothermia, hypoventilation, and hyponatremia. There is no evidence to suggest that patients with mild to moderate hypothyroidism are at increased risk for anesthetic complications, but all elective surgery patients should be treated with thyroid hormone replacement before surgery. Severe hypothyroidism resulting in myxedema coma is a medical emergency and is associated with a high mortality rate. Intravenous infusion of T3 or T4 and glucocorticoids should be combined with ventilatory support and temperature control as needed.

Parathyroid

The prevalence of primary hyperparathyroidism increases with age. Of patients with primary hyperparathyroidism, 60% to 70% present initially with nephrolithiasis secondary to hypercalcemia, and 90% are found to have benign parathyroid adenomas. Hyperparathyroidism secondary to hyperplasia occurs in association with medullary thyroid cancer and pheochromocytoma in multiple endocrine neoplasia type IIA and, more rarely, with malignancy. In humoral hypercalcemia of malignancy, nonendocrine tumors have been demonstrated to secrete a parathyroid hormone-like protein. Secondary hyperparathyroidism usually results from chronic renal disease. The hypocalcemia and hyperphosphatemia associated with this condition lead to increased parathyroid hormone production and, over time, to parathyroid hyperplasia. Tertiary hyperparathyroidism occurs when the CRF is rapidly corrected as occurs in renal transplantation.

In addition to nephrolithiasis, signs and symptoms of hypercalcemia include polyuria, polydipsia, skeletal muscle weakness, epigastric discomfort, peptic ulceration, and constipation. Radiographs may show significant bone resorption in 10% to 15% of patients. Depression, confusion, and psychosis also may be associated with marked elevations in serum calcium levels.

Immediate treatment of hypercalcemia usually combines sodium diuresis with a loop diuretic and rehydration with normal saline as needed. This becomes urgent once the serum calcium levels rise above 15 g/dL. Several medications can be used to decrease serum calcium levels. Etidronate inhibits abnormal bone resorption. The cytotoxic agent mithramycin inhibits parathyroid hormone–induced osteoclastic activity but is associated with significant side effects, and calcitonin works transiently again by direct inhibition of osteoclast activity. Hemodialysis can also be used in the appropriate patient population.

The most common cause of hypoparathyroidism is iatrogenic. Thyroid and parathyroid surgery occasionally results in the inadvertent removal of all parathyroid tissue. Ablation of parathyroid tissue can also occur after major head and neck surgery and postoperative radiation therapy. Symptoms include tetany, perioral and digital paresthesias, muscle spasm, and seizures. Chvostek’s sign (facial nerve hyperactivity elicited by tapping over the common trunk of the nerve as it passes through the parotid gland) and Trousseau’s sign (finger and wrist spasm after inflation of a blood pressure cuff for several minutes) are clinically important indicators of latent hypocalcemia. Treatment is with calcium supplementation and vitamin D analogs.

Adrenal

Adrenal gland hyperactivity can result from a pituitary adenoma, a corticotropin hormone (ACTH)-producing nonendocrine tumor, or a primary adrenal neoplasm. Symptoms include truncal obesity, proximal muscle wasting, “moon” facies, and changes in behavior that vary from emotional lability to frank psychosis. Diagnosis is made through the dexamethasone suppression test, and treatment is adrenalectomy or hypophysectomy. It is important to regulate blood pressure and serum glucose levels and to normalize intravascular volume and electrolytes. Primary aldosteronism (Conn’s syndrome) results in increased renal tubular exchange of sodium for potassium and hydrogen ions. This leads to hypokalemia, skeletal muscle weakness, fatigue, and acidosis. The aldosterone antagonist spironolactone should be used if the patient requires diuresis.

Idiopathic primary adrenal insufficiency (Addison’s disease) results in both glucocorticoid and mineralocorticoid deficiencies. Symptoms include asthenia, weight loss, anorexia, abdominal pain, nausea, vomiting, diarrhea, constipation, hypotension, and hyperpigmentation. Hyperpigmentation is caused by overproduction of ACTH and beta-lipotropin, which leads to melanocyte proliferation. Measurement of plasma cortisol levels 30 and 60 minutes after intravenous administration of ACTH (250 mg) aids in diagnosis. Patients with primary adrenal insufficiency demonstrate no response. Glucocorticoid replacement is required on a twice-daily basis and should be increased with stress. Mineralocorticoid therapy can be given once daily. Of note, patients treated for more than 3 weeks with exogenous glucocorticoids for any medical condition should be assumed to have suppression of their adrenal-pituitary axis and should be treated with stress-dose steroids perioperatively.

Pheochromocytoma is a tumor of the adrenal medulla that secretes both epinephrine and norepinephrine. Of these tumors, 5% are inherited in an autosomal dominant fashion as part of a multiple endocrine neoplasia syndrome. Symptoms include hypertension (which is often episodic), headache, palpitations, tremor, and profuse sweating. Preoperative treatment begins with phenoxybenzamine (a long-acting alpha-blocker) or prazosin at least 10 days before surgery. A beta-blocker is added only after the establishment of alpha-blockade to avoid unopposed beta-mediated vasoconstriction. Acute hypertensive crises can be managed with nitroprusside or phentolamine.

Diabetes Mellitus

Diabetes is a disorder of carbohydrate metabolism that results in a wide range of systemic manifestations. It is the most common endocrine abnormality found in surgical patients and can be characterized as either insulin-dependent (type I or juvenile onset) or non–insulin-dependent (type II). Hyperglycemia may result from a variety of etiologies that affect insulin production and function. Management techniques seek to avoid hypoglycemia and maintain high-normal serum glucose levels throughout the perioperative period. These goals are often difficult to maintain, however, because infection, stress, exogenous steroids, and variations in carbohydrate intake can all cause wide fluctuations in serum glucose levels. Close monitoring is mandatory with correction of hyperglycemia, using a sliding scale for insulin dosage or continuous intravenous infusion in more severe cases. Fluid management should focus on maintaining hydration and electrolyte balance.

Hematologic Disorders

A history of easy bruising or excessive bleeding with prior surgery should raise suspicion of a possible hematologic diathesis. A significant number of patients will also present on anticoagulative therapy for coexisting medical conditions. After a careful history, the physician should obtain laboratory studies. PT, PTT, and platelet count are included in the routine preoperative screen. PT evaluates both the extrinsic and the final common pathways. Included in the extrinsic pathway are the vitamin K–dependent factors II, VII, IX, and X, which are inhibited by warfarin. Conversely, heparin inhibits thrombin and factors IXa, Xa, and XIa, elements of the intrinsic clotting pathway. PTT measures the effectiveness of the intrinsic and final common pathways. Relative to the normal population, some patients may demonstrate significant variation in the quantitative levels of certain factors in the absence of clinically relevant clotting abnormalities. Thrombocytopenia or platelet dysfunction can also lead to derangements in coagulation. A standard CBC includes a platelet count, which should be greater than 50,000 to 70,000 before surgery. The ivy bleeding time, a clinical test of platelet function, should be between 3 and 8 minutes. Fibrin split products may also be measured to help determine the diagnosis of disseminated intravascular coagulation.

Congenital

Congenital deficiencies of hemostasis affect up to 1% of the population. The majority of these deficiencies are clinically mild. Two of the more serious deficiencies involve factor VIII, which is a complex of two subunits, factor VIII:C and factor VIII:von Willebrand’s factor. Gender-linked recessive transmission of defects in the quantity and quality of factor VIII:C leads to hemophilia A. Because of its short half-life, perioperative management of factor VIII:C requires infusion of cryoprecipitate every 8 hours. The disease that has a milder presentation than hemophilia A is von Willebrand’s disease, in which bleeding tends to be mucosal rather than visceral.

This disease is categorized into three subtypes. Types I and II represent quantitative and qualitative deficiencies, respectively. These deficiencies are passed by autosomal dominant transmission. Type I von Willebrand’s also is characterized by low levels of factor VIII:C. Type III von Willebrand’s disease is much rarer and presents with symptoms similar to those of hemophilia A. Because of the longer half-life of factor VIII:von Willebrand’s factor, patients with type II von Willebrand’s disease can be transfused with cryoprecipitate up to 24 hours before surgery, with repeat infusions every 24 to 48 hours. Patients with type I von Willebrand’s disease require additional transfusion just before surgery to boost factor VIII:C levels and normalize bleeding time.

Patients with hemophilia, von Willebrand’s disease, and other less common congenital hemostatic anomalies should be followed perioperatively by a hematologist. Correction of factor deficiencies should be instituted in a timely fashion, and patients should be monitored closely for any evidence of bleeding.

Anticoagulants

Warfarin, heparin, and aspirin have become commonly used medications in the medical arsenal. Conditions such as atrial fibrillation, deep vein thrombosis, pulmonary embolism, and heart valve replacement are routinely treated initially with heparin, followed by warfarin on an outpatient basis. This therapy markedly decreases the incidence of thromboembolic events and, when appropriately monitored, only slightly increases the risk of hemorrhagic complications. Aspirin is widely used both as an analgesic and as prophylaxis for coronary artery disease. Patients taking any of these medications need careful evaluation to assess the severity of the condition necessitating anticoagulation. The benefit of surgery relative to the risk of normalizing coagulation should be clearly established with both the patient and the physician prescribing the anticoagulant.

Warfarin should be stopped at least 3 days before surgery, depending on liver function. Patients who have been determined to be at high risk for thromboembolism should be admitted for heparinization before surgery. The infusion rate can then be adjusted to maintain the PTT in a therapeutic range. Discontinuation of heparin approximately 6 hours before surgery should provide adequate time for reversal of anticoagulation. In emergency situations, warfarin can be reversed with vitamin K in approximately 6 hours and more quickly with the infusion of fresh frozen plasma (FFP). Heparin effects can be reversed with protamine or FFP. Of note, a heparin rebound phenomenon in which anticoagulative effects are reestablished can occur up to 24 hours after the use of protamine. Anticoagulative therapy can be reinstituted soon after surgery if necessary. Most surgeons, however, prefer to wait several days unless contraindicated. The surgeon may often find it helpful to discuss the timing of postoperative therapy with the hematologist before surgery.

Aspirin, an irreversible inhibitor of platelet function, leads to prolonged bleeding time. No strong evidence links aspirin therapy with excessive intraoperative bleeding. However, the theoretical risk that aspirin and other nonsteroidal anti-inflammatory medications present leads most surgeons to request that their patients stop taking these medications up to 2 weeks before surgery to allow the platelet population to turn over.

Liver Failure

Patients with liver failure can present with several hematologic abnormalities. Bleeding from esophageal varices secondary to portal hypertension can lead to anemia. Hypersplenism and alcoholic bone marrow suppression can result in serious thrombocytopenia. An elevated PT may indicate a deficiency in the vitamin K–dependent factors of the extrinsic clotting pathway, as well as factors I, V, and XI, which are also produced in the liver. Last, as liver failure progresses, excessive fibrinolysis may occur. All of these hematologic sequelae of hepatic failure increase the risk of operative morbidity and mortality. Preoperative management should attempt to correct anemia and thrombocytopenia as indicated and replenish deficient clotting factors with FFP. Fluid management may prove to be a difficult issue.

Another less common cause of PT elevation is the intestinal sterilization syndrome in which intestinal flora, a major source of vitamin K, are eradicated by prolonged doses of antibiotics in patients unable to obtain vitamin K from other sources. Reversal occurs rapidly with vitamin K therapy.

Thrombocytopenia

A decrease in platelet count can occur as a result of a variety of medical conditions, including massive transfusion, liver failure, disseminated intravascular coagulation, aplastic anemia, hematologic malignancy, and idiopathic thrombocytopenic purpura. With the increasing use of chemotherapeutics for a variety of malignancies, the prevalence of iatrogenic thrombocytopenia has risen. Preoperatively, the platelet count should be greater than 50,000; at levels below 20,000, spontaneous bleeding may occur. Additionally, any indication of platelet dysfunction should be evaluated with a bleeding time. Severe azotemia secondary to renal failure may lead to platelet dysfunction (uremic platelet syndrome). Dialysis should be performed as necessary.

Correction of thrombocytopenia with platelet transfusion should preferably come from human leukocyte antigen–matched donors, particularly in patients who have received prior platelet transfusions and may be sensitized. One unit of platelets contains approximately 5.5 × 1011 platelets. One unit per 10 kg of body weight is a good initial dose. The platelets should be infused rapidly just before surgery.

Hemoglobinopathies

Of the more than 300 hemoglobinopathies, sickle cell disease and thalassemia are by far the most common. Approximately 10% of blacks in the United States carry the gene for sickle cell anemia. The heterozygous state imparts no real anesthetic risk. There are significant clinical manifestations to the 1 in 400 blacks who are homozygous for hemoglobin S. The genetic mutation results in the substitution of valine for glutamic acid in the sixth position of the beta-chain of the hemoglobin molecule, leading to alterations in the shape of erythrocytes when the hemoglobin deoxygenates. The propensity for sickling directly relates to the quantity of hemoglobin S. Clinical findings include anemia and chronic hemolysis. Infarction of multiple organ systems can occur secondary to vessel occlusion. Treatment consists of preventive measures. Oxygenation and hydration help maintain tissue perfusion. Transfusion before surgical procedures decreases the concentration of erythrocytes carrying hemoglobin S, thereby lowering the chance of sickling.

Multiple types of thalassemia exist, each caused by genetic mutations in one of the subunits of the hemoglobin molecule. Symptoms vary on the severity of the mutation. Patients with the most severe form, beta-thalassemia major, are transfusion-dependent, which often leads to iron toxicity. Other thalassemias cause only mild hemolytic anemia. If transfusion dependency exists, the patient should be screened carefully for hepatic and cardiac sequelae of iron toxicity.

Neurologic

For medicolegal reasons, it is critical to document all neurologic abnormalities. The surgeon should distinguish peripheral from central lesions, and CT or MRI is often helpful in this regard. Frequently, neurologic consultation is sought in the setting of subtle findings or confusing or paradoxic findings and for evaluation of possible nonotolaryngologic etiologies of certain complaints, such as headache and dysequilibrium. During preoperative patient counseling, the surgeon must be aware of the potential for nerve injury or sacrifice and must communicate the possible sequelae of these actions to the patient.

If the patient has a history of seizures, the surgeon needs to find out the type, pattern, and frequency of the epilepsy, as well as the current anticonvulsant medications in use and their side effects. Phenytoin therapy can lead to poor dentition and anemia, whereas treatment with carbamazepine can cause hepatic dysfunction, hyponatremia, thrombocytopenia, and leukopenia, all of which represent concerns for the surgeon and anesthesiologist. Preoperative CBC, liver function tests, and coagulation studies are thus advised. Anesthetic agents such as enflurane, propofol, and lidocaine have the potential to precipitate convulsant activity, depending on their doses. In general, antiseizure medications must be at therapeutic serum levels and should be continued up to and including the day of surgery.

Symptomatic autonomic dysfunction can contribute to intraoperative hypotension. It may be necessary to augment intravascular volume preoperatively through increasing dietary salt intake, maximizing hydration, and administering fludrocortisone.

Additional considerations must be taken into account in patients with upper motor neuron diseases, such as amyotrophic lateral sclerosis, or lower motor neuron processes affecting cranial nerve nuclei in the brainstem. In either case, the otolaryngologist may be confronted with bulbar symptoms such as dysphagia, dysphonia, and inefficient mastication. As bulbar impairment progresses, the risk of aspiration increases significantly. When respiratory muscles are affected, the patient is likely to have dyspnea, intolerance to lying flat, and an ineffective cough. Coupled with aspiration, these factors put the patient at considerable surgical risk for pulmonary complications. Hence, if surgery is necessary for these patients, preoperative evaluation should include a pulmonary workup (including chest radiography, pulmonary function tests, ABG analysis) and consultation. A video study of swallowing function may also be indicated. Finally, the patient’s neurologist should be closely involved in the decision making (i.e., whether to proceed with surgery).

Parkinsonism presents the challenges of excessive salivation and bronchial secretions, gastroesophageal reflux, obstructive and central sleep apnea, and autonomic insufficiency, all of which predispose to difficult airway and blood pressure management in the perioperative period. Dopaminergic medications should be administered up to the time of surgery to avoid the potentially fatal neuroleptic malignant syndrome. Medications such as phenothiazines, metoclopramide, and other antidopaminergics should be avoided. Preoperatively, the patient’s pulmonary function and autonomic stability should be investigated.

If clinically indicated, patients with multiple sclerosis should also undergo full pulmonary evaluation preoperatively, because these patients can present with poor respiratory and bulbar function. The presence of contractures can limit patient positioning on the operating table. In addition, before surgery, the patient must be free of infection because pyrexia can exacerbate the conduction block in demyelinated neurons.

Older Patients

Of all surgeries currently performed, 25% to 33% are performed on people older than 65 years of age. This percentage is likely to increase as the population ages. A greater likelihood of comorbid conditions exists with increasing age. In addition, physiologic reserve is often compromised. Preoperative assessment in this population should take these considerations into account and weigh the benefit of the procedure against the often increased risks in this population. Consultation with the anesthesia service facilitates planning for high-risk older patients.

Approximately 50% of all postoperative deaths in older adults occur secondary to cardiovascular events. Severe cardiac disease should be treated before any elective procedure and should be weighed against the benefit of any more urgent procedure. If surgery is required, cardiac precautions should be instituted. Patients with physical evidence or a history of peripheral vascular disease should be evaluated for carotid artery stenosis. If a critical stenosis is identified, carotid endarterectomy should be performed before any elective procedure that requires a general anesthetic. The risk of a cerebrovascular accident should be considered when evaluating patients for more urgent procedures. From a respiratory standpoint, increasing age leads to loss of lung compliance, stiffening of the chest wall, and atrophy of respiratory muscles. In many otolaryngology procedures, the surgeon should consider the risk of intraoperative or postoperative aspiration and postobstructive pulmonary edema. Patients with borderline pulmonary function may not tolerate even mild respiratory complications. The function of all the organ systems diminishes with age, necessitating a thorough preoperative evaluation to maximize older patient safety.

Conclusion

This chapter provides a brief overview of the importance for the surgeon to gather a patient’s history and complete a physical examination and preoperative evaluation. Disturbances in one organ system often have repercussions for other systems, so an interdisciplinary approach involving the otolaryngologist, anesthesiologist, internist, and specialized consultants is often warranted. This chapter emphasizes the physiologic aspects of the evaluation, without intending to overshadow the importance of gaining insight into a patient’s psychosocial preparedness, which often requires the help of family members, social workers, psychiatrists, and support groups, as well as a keen sense of intuition on the part of the surgeon. Furthermore, the surgeon’s preoperative discussions with the patient provide a means to reinforce the patient’s postoperative expectations and coping mechanisms. Finally, the responsibility of ensuring an appropriate preoperative evaluation lies with the surgeon and the expediency of this process should be in keeping with the best interests of the patient.

SUGGESTED READINGS

Adkins RBJr. Preoperative assessment of the elderly patient. In: Cameron JL, editor. Current Surgical Therapy. St Louis: Mosby, 1992.

Buckley FP. Anesthesia and obesity and gastrointestinal disorders. In: Barash PG, Cullen BF, Stoelting RK, editors. Clinical Anesthesia. Philadelphia: JB Lippincott, 1989.

Curzen N. Patients with permanent pacemakers in situ. In: Goldstone JC, Pollard BJ, editors. Handbook of Clinical Anesthesia. New York: Churchill Livingstone, 1996.

Davies W. Coronary artery disease. In: Goldstone JC, Pollard BJ, editors. Handbook of Clinical Anesthesia. New York: Churchill Livingstone, 1996.

Ellison N. Hemostasis and hemotherapy. In: Barash PG, Cullen BF, Stoelting RK, editors. Clinical Anesthesia. Philadelphia: JB Lippincott, 1989.

Gelman S. Anesthesia and the liver. In: Barash PG, Cullen BF, Stoelting RK, editors. Clinical Anesthesia. Philadelphia: JB Lippincott, 1989.

Goldstone JC. COPD and anesthesia. In: Goldstone JC, Pollard BJ, editors. Handbook of Clinical Anesthesia. New York: Churchill Livingstone, 1996.

Graf G, Rosenbaum S. Anesthesia and the endocrine system. In: Barash PG, Cullen BF, Stoelting RK, editors. Clinical Anesthesia. Philadelphia: JB Lippincott, 1989.

Hirsch NP, Smith M. Central nervous system. In: Goldstone JC, Pollard BJ, editors. Handbook of Clinical Anesthesia. New York: Churchill Livingstone, 1996.

Hurford WE. Specific considerations with pulmonary disease. In Firestone LL, Lebowitz PW, Cook CE, editors: Clinical Anesthesia Procedures of the Massachusetts General Hospital, ed 3, Boston/Toronto: Little, Brown, 1988.

Kovatsis PG. Specific considerations with renal disease. In Davidson JK, Eckhardt WFIII, Perese DA, editors: Clinical Anesthesia Procedures of the Massachusetts General Hospital, ed 4, Boston/Toronto/London: Little, Brown, 1993.

Long TJ. General preanesthetic evaluation. In Davidson JK, Eckhardt WFIII, Perese DA, editors: Clinical Anesthesia Procedures of the Massachusetts General Hospital, ed 4, Boston/Toronto/London: Little, Brown, 1993.

Morgan C. Cardiovascular disease, general considerations. In: Goldstone JC, Pollard BJ, editors. Handbook of Clinical Anesthesia. New York: Churchill Livingstone, 1996.

Robbins KT, Clayman G, Levine PA, et al. Neck dissection classification update. Revisions proposed by the American Head and Neck Society and the American Academy of Otolaryngology–Head and Neck Surgery. Arch Otolaryngol Head Neck Surg. 2002;128:751.

Rotter S. Specific considerations with cardiac disease. In Davidson JK, Eckhardt WFIII, Perese DA, editors: Clinical Anesthesia Procedures of the Massachusetts General Hospital, ed 4, Boston/Toronto/London: Little, Brown, 1993.

Strang T, Tupper-Carey D. Allergic reaction. In: Goldstone JC, Pollard BJ, editors. Handbook of Clinical Anesthesia. New York: Churchill Livingstone, 1996.

Sussman GL, Beezhold DH. Allergy to latex rubber. Ann Intern Med. 1995;122:43.

Vandam LD, Desai SP. Evaluation of the patient and preoperative preparation. In: Barash PG, Cullen BF, Stoelting RK, editors. Clinical Anesthesia. Philadelphia: JB Lippincott, 1989.

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