Rhinoplasty Dr Bashar Bizrah Article on: Local Anaesthesia

Rhinoplastic surgeons have a duty to dispel the horror stories that have become associated with nasal surgery and general anaesthesia. We were urged to apply and develop the technique of local anaesthesia with sedation, in order to reduce the patient’s fear caused by general anaesthesia and to provide a more safe, comfortable and convenient procedure. The application of local anaesthesia with sedation has resulted in shorter hospitalization, shorter total operative time, shorter recovery and quicker turnover of cases, less frequent nausea and vomiting, less operative and intraoperative bleeding and it is more appropriate for patients with asthma, diabetes and hypertension. Local anaesthesia is not recommended for patients under the age of sixteen or the worried and irritable type of patients. The author currently applies local anaesthesia in over 80% of his cases.

Technique of local anaesthesia with sedation:
The local anaesthesia procedure must have been fully explained to the patient at his consultation visit. Patient selection is important, the patient should be cooperative, understanding and willing for local anaesthesia. Many patients, unfortunately, are horrified about anaesthesia. For this reason, the author’s approach to local anaesthesia is based on his own experience and that of others, which is designed to provide a more safe and acceptable procedure. The patient is adequately sedated and has amnesia to much of the operating room experience, but usually is aroused easily by talking to him and alert on returning to the ward. This approach allows early mobilization and the patient is discharged home on the same day. The sedation is administered in a planned and progressive manner, premedication is given on admission one hour before surgery, then in the operating room the intravenous sedation is administered under the supervision of a trained Anaesthesiologist. Once the patient has reached his state of sedation, topical and injectable anaesthetics are delivered to the areas to be operated. (Figs. 3 -1,2,3)

1. Preoperative medication: one hour before surgery while patient is still in his room.

Diazepam 5mg	oral or i.m.
Zofran 4mg (Ondansetron)	oral
Decadron 8mg (Dexametason)	Intravenous
Zinacef 1.5mg (Cefuroxim)	Intravenous
Iliadine (Oxymetazoline hydrochloride) nostril	3 drops each
Emla cream (Lidocaine, Prilocaine)	on the nose and vestibular skin

Fig. 3 - 1. Nerve supply to the external nose.

Fig. 3 - 2. Nerve supply of the lateral nasal wall.

Fig. 3 - 3. Nerve supply of the nasal septum.

2. Patient monitoring: In the operating room, an ECG, pulse, respiratory, P02 and PC02 monitoring should be connected to the patient before any intraoperative sedation or local anaesthetic injection.
3. Intraoperative sedation: Intravenous sedation is given before the use of any sprays, local injections or packs.
   Sedation: starts with:
   
   • Dormicum (Midazolam) 2mg/IV
     
   • Pethidine 30mg/ IV
     Xylocaine spray 4%: two puffs in each nostril then wait for three minutes.
4. T apical anaesthesia:
   Our aim is to eliminate pain and to achieve vasoconstriction. Xylocaine or Lidocaine
   2 % with 1:200,000 Epinephrine in 5cc syringe and 27 gauge needle is used. A series
   of bolus injections and infiltration are administered as follows:

• of bolus injections and infiltration are administered as follows:
• The anterior end of the inferior turbinate. (Fig. 3 – 4)
• Submucously, high under the nasal bones to the region of the anterior ethmoid nerve.
• Site of the caudal septum and transfixion incision. (Fig. 3 – 5)
• Site of intercartilagenous incision.
• Superior septal angle: the needle is passed through in the midline to the rhinion and up to nasion, a bolus is injected along each of these three sites.
• Site of the marginal incision at the mid lateral crus, then at one cm intervals along the caudal lateral crus.
• Bolus at mid-columellar between the two medial crus, then a bolus up between the domes and a bolus down at the base of the columella.
• Infiltrating along the nasofacial junction. The entry site is intranasally at the pyriform aperture, then the needle is pushed to a midpoint between the medial canthus and the nasion, then pulled while infiltrating. Care should be taken not to enter the angular vein.
• Bolus to the alar base at the nasolabial junction. The needle is pushed down to meet the bone then pulled while infiltrating.
• Bolus at the frenulum intraorally, behind the upper lip.

One should never overinfiltrate the nose with local anaesthesia, 5cc is quite enough. Overinfiltration causes swelling of tissue, leading to incorrect assessment such as false overprojection, false hump, masking of depressions and mild deviations and widening the base of the nose. This will lead to overcorrection and later complications.

Fig. 3 - 4. (1,2,3,4,5,6,7,8) Series of bolous injections of Xylocaine 2% w ith 1 :200,000 Epinephrine are administered to the sites of osteotomies, intercartilagenous and transfixion incisions, marginal incisions, nasion, alar base, and anterior end of inferior turbinates.

Fig. 3 - 5. (9, 10, 11, 12) Local infiltration to the marginal incision and the frenulum. (13, 14, 15, 16) Demonstrate the sites of intercartilagenous and transfixion incisions.

5. Nasal anaesthetic pack:
   A light nasal pack soaked with Xylocaine gel, Prisoline and Sec Xylocaine with 1:100,000 Adrenaline. The nasal cavity is packed in a way as to cover the regions of the sphenopalatine ganglion posteriorly, anterior ethmoid nerves under the nasal bones and the pack is made in layers to cover as much of the septum and inferior turbinates. Each pack is sutured to a long silk tie, the tie is fixed with plaster to the
   cheek. (Fig. 3 – 6)
6. The procedure starts after fifteen minutes in order to allow time for vasoconstriction and amnesia. Once we start the procedure, the light nasal pack is pushed backward to close the posterior choana to prevent dripping of blood to the throat during surgery. The pack is fixed with a silk tie to the cheek to prevent the pack slipping into the oropharynx. The vestibular hair is trimmed at this stage.
7. Maintaining the sedation:
   During the procedure, the sedation is maintained by one mg of Dormicum and ten mg of Pethidine every fifteen minutes. To reduce nausea, Zofran 4mg is given on continuous intravenous drip. The average time of our Septorhinoplasty is sixty minutes. Naloxon may be used for overdose.
8. A trained Anaesthesiologist should be present and should stay at the head of the patient watching the ECG, P02 , PC02 , vital signs and the airways. Should the patient become agitated or uncooperative during the procedure, the Anaesthesiologist should be quite prepared to administer general anaesthesia. Nasal procedures under local anaesthesia should be carried out in a fully ready and equipped operating room.

Fig. 3 - 6. (17, 18, 19,20) Local anaesthesia demonstrates the sites of transfixion and marginal incisions and external rhinoplasty incisions. (21,22,23,24) Nasal pack: a light nasal pack soaked w ith Xylocaine gel, Prisoline and Sec Xylocaine with 1: 100,000 Adrenaline. The nasal cavity is packed in a way to cover the region of the sphenopalatine ganglion and the anterior ethmoid neNes under the nasal bones. The pack is made in layers to cover as much of the septum and inferior turbinates as possible. Each pack is sutured to a long silk tie, the tie is then fixed w ith plaster to the cheek.

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