Moderate Sedation vs. General Anesthesia for Outpatient ENT Surgery

Ear, nose, and throat surgeries that previously were exclusively done in the inpatient setting can now increasingly be done outpatient with few complications, thanks to technological advantages in outpatient surgery.¹ Generally, the decision of which location the surgery is performed in depends on the surgeon’s comfort, the patient’s comorbidities, and the facility resources. The anesthesia approach does not differ greatly between both settings. The decision of moderate sedation versus general anesthesia for outpatient ENT surgery depends on the procedure being done and the patient’s comorbidities.

Moderate sedation may be used for more superficial surgeries that do not have a high risk of endangering the patient’s airway. Lower risk surgeries include flexible laryngoscopy, nasal polypectomy, and foreign body removal.¹ Any surgeries that require active medical monitoring overnight post-op, involve major blood loss, are emergent, or require systemic thrombolytic therapy are not suitable for anesthesia in the outpatient setting.

The patient’s comorbidities are another important factor when deciding to do outpatient surgery and the subsequent anesthesia method. The American Society of Anesthesiologists have a classification system for patients’ physical health status. ASA class 1 are healthy patients while ASA class 4 are patients with severe systemic disease that is a threat to life. Patients that are ASA class 3 or 4, are over 80 years old, or have BMI over 35 kg/m² are more likely to have hospital admission after general anesthesia and thus are not good surgical candidates in the outpatient setting. Generally, healthier patients are better candidates for any type of anesthesia, particularly general anesthesia.

General anesthesia is used frequently for ENT surgery because it allows the surgical team to take over and ensure the patient’s airway, provides reliable anesthesia, and does not allow for excessive movement. The preferred anesthesia methods used for head and neck procedures is a combination of inhaled anesthetics and IV anesthetics, usually a combination of target-controlled infusion of propofol and opioids.² The combination of propofol and opioids have synergistic activity to quickly titrate anesthesia to the desired levels. In addition, head and neck surgeries may increase the likelihood of postoperative emesis, which propofol can reduce the risk of. Opioids help reduce mild to moderate postoperative pain.

The COVID-19 pandemic has impacted availability of elective outpatient surgeries. Head and neck surgeons have a greater risk of infection compared to other surgeons due to where on the body they operate. Because of this risk, health care facilities and surgeons should prioritize urgent procedures for stabilization. Elective care can be considered on a case-by-case basis, especially for cancer patients.³ Of note, there is preferential use of total IV anesthesia in the ambulatory setting to increase the safety of the patient and the healthcare team. The exclusive use of IV anesthesia over inhaled anesthetics reduces the risk of viral spread via coughing. Additionally, IV anesthesia has faster recovery rates compared to inhaled anesthetics. Faster recovery post-operatively decreases the amount of time patients are in the recovery room, which reduces risk of exposure from patients to other patients and healthcare staff.

In summary, current recommendations for outpatient ENT surgery during the COVID-19 pandemic is a combination of IV anesthesia and opioids. Recommendations do not vary widely from inpatient anesthetic treatment.

References

1. Rodriguez LV. Anesthesia for Ambulatory and Office-Based Ear, Nose, and Throat Surgery. Otolaryngol Clin North Am. 2019 Dec;52(6):1157-1167. doi: 10.1016/j.otc.2019.08.012. Epub 2019 Sep 21. PMID: 31551126.
2. Ewalenko P, Deloof T, Gerin M, Delmotte JJ, Byttebier G. Propofol infusion with or without fentanyl supplementation for microlaryngoscopy. Acta Anaesthesiol Belg. 1990;41(4):297-306. PMID: 2085082.
3. Stewart M, Thaler A, Hunt P, Estephan L, Boon M, Huntley C. Preferential use of total intravenous anesthesia in ambulatory otolaryngology surgery during the COVID-19 pandemic. Am J Otolaryngol. 2020 Sep-Oct;41(5):102570. doi: 10.1016/j.amjoto.2020.102570. Epub 2020 Jun 1. PMID: 32505994; PMCID: PMC7263220.