Update 11/2023

(specific to U of Iowa Otolaryngology - with modifications per individual attendings)

ANESTHESIA CONSIDERATIONS

1. Bed will be turned 180 degrees, which will likely require extenders for the anesthesia ventilation circuit to reach
2. Anesthetic paralysis (full relaxation) OK in general
3. Standard endotracheal tube (ETT) should be taped to the left lip with no tape crossing the upper lip except when septoplasty is also being performed.
   1. Facial plastics team may prefer RAE tube taped to the middle for symmetry 
      1. RAE tube named after inventors (Ring,Adair and Elwyn) (Ring 1975) 
      2. RAE tubes with preformed bend - discussion about advantages and disadvantages: UCSF Anesthesia Airway Management: (https://aam.ucsf.edu/rae-tubes accessed 12-07-2023)
4. Transsphenoidals will need an art line, though regular sinus cases do not

STEALTH SET UP

1. Obtain a stealth machine from the half moon room outside of MOR 23/24. Make sure to check if it has been reserved/setup for a neurosurgery case already. If it has, then obtain a different one.
2. Turn the machine on and login. Password is "stealth".
3. Select ENT, followed by FESS (regardless of whether this is true or not). This setting has all of the correct tools registered that would be used in standard FESS, transphenoidals, or anterior skull base dissections.
4. Upload the patient data. All of the stealth machines are connected to the wifi network, but the previously used ethernet cable and CD methods are also included for need in a pinch.
   1. Wifi method
      1. Give the machine time to connect to the network
      2. Enter the patient MRN, and select their pre-operative stealth scan. CT max/face can also be used if no stealth is available.
      3. Select the axial scan with the highest image count to upload DICOMM data to the system
   2. Ethernet cable method (Best method if wifi is down)
      1. Connect the stealth machine to one of the ethernet jacks in the half moon room with the blue ethernet cables
      2. Enter the patient MRN, and select their pre-operative stealth scan. CT max/face can also be used if no stealth is available.
      3. Select the axial scan with the highest image count to upload DICOMM data to the system
   3. CD method (must contact radiology 1-2 days in advance to have the disk prepared)
      1. Put in CD and select "Standard DICOMM formatted" and wait for it to load, then click "Next"
5. Bring both the stealth machine and one of the black suitcases to the operating room. 
6. Put the stealth machine in the room opposite of anesthesia.
7. Remove the flat panel from the black suitcase, put it within a green pillow case, and place it at the head of the bed. 
8. Place a large flat gel over only the portion of the flat panel where the patient's shoulders will rest to prevent pressure injuries.

PATIENT PREP/REGISTRATION

1. After intubation as above, use Afrin nasal spray before turning the bed 180 degrees - head to be away from anesthesia.
2. Position the patient's body close to the right side of the bed with their head turned slightly right and HOB up 30 degrees. Lower the table all of the way down.
3. Remove the arm board from the right side and tuck the patient's right arm. The armboard can remain on the left side unless it is a combo case with Neurosurgery and a fat graft might need to be harvested.
4. Spray the bialteral nasal cavities with afrin.
5. Additional prep may include
   1. Use 1% lidocaine with 1:100,000 epinephrine to inject bilateral greater palatine foramina (1cc to each side)
   2. Place throat pack (and let nursing know you did this) - check throat pack sign on the door
6. Pull the stealth machine to the head of the bed such that the screen is about 2 feet from the patient.
7. Connect the flat panel to the stealth machine, and place the black foot pedal such that it is easy to reach for registration.
8. Drape face with towels widely to allow for registration and then split sheet. Towel off so the mouth is out of your field, but the eyes, forehead, and cheeks are included.
9. Register the stealth
   1. Trace registration
      1. Use the registration probe device and hold it on the skin and trace along forehead and down the nose and back up until the machine stops beeping
   2. Touch points (Dr. Walsh will have you add 4 touch points)
      1. On the registration screen, select the Touch Point option.
      2. Click on the 3D reconstruction of the patient where you would roughly want the touch point. 
      3. Use the coronal, sagittal, and axial screens to optimize the point positioning on the desired landmark.
      4. Repeat to set up each touch point
         1. Dr. Walsh likes to use the bilateral lateral commisures, the base of the nasal columella, and the nasion

OTHER TOOLS

1. Microdebrider should be set at 3000 oscillate - use Fusion blade
2. White balance the endoscope and use to inspect the nose
   1. Inject the septum (anterior for sinus cases, posterior for transsphenoidal) - note this injection process is surgeon dependent
   2. Pack the nose with Afrin-soaked pledgets (1/2" x 1/2") on either side
      1. Medial to middle turbinate for transsphenoidal, lateral for sinus
      2. Some affirm need to pledgets to be in for at least 10 minutes

References

Ring, W. H.; Adair, J. C.; Elwyn, R. A. (1975): A new pediatric endotracheal tube. In Anesthesia and Analgesia 54 (2), pp. 273–274.

UCSF Anesthesia Airway Management RAE tubes | Anesthesia Airway Management (AAM) (ucsf.edu) https://aam.ucsf.edu/rae-tubes accessed 12-07-2023