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Although rare, cannot intubate and cannot oxygenate situations are challenging acute events. The development of management algorithms, standardized equipment provisions, and appropriate clinical training in the application of front-of-neck access techniques are necessary to optimize procedural success to ensure adequate oxygenation. The OxyTain algorithm is an institutionally developed protocol to manage cannot intubate and cannot oxygenate events. With proper implementation, this unique process aligning the cannula cricothyroidotomy and scalpel bougie as primary and secondary techniques, respectively, can potentially optimize procedural success. This algorithmic approach is trained routinely among our anesthesia providers, while the equipment is standardized throughout our anesthetizing locations.

Objectives: Current Accreditation Council for Graduate Medical Education (ACGME) requirements allow PGY-1 otolaryngology-head and neck surgery (ORL-HNS) residents to spend 6 months on service, prompting reconsideration of educational best practices for the first-year resident experience. The aim of this study was to determine feasibility and value of a 1-month PGY-1 otolaryngology clinical skills rotation integrated with anesthesiology to complement clinical ORL-HNS rotations. Methods: Our institution developed a 1-month rotation focusing on procedural simulation and airway management as a collaborative effort between ORL-HNS and anesthesiology. Logistics of curriculum design and implementation in the first 2 years are described. Learner outcome measures include pre- and postintervention Likert scale measures of knowledge and confidence. Statistical assessment of curriculum efficacy includes Wilcoxon sign rank test and effect size (Cohen’s d). Results: The described rotation was successfully implemented for 8 entering PGY-1 residents in the 2016-2017 and 2017-1018 academic years. Learners reported significant improvement in knowledge and confidence (5-point Likert scale, all P < .0001) in each of the following grouped domains following the intervention: anesthesia skills (pre 2.79, post 4.02), anesthesia knowledge (pre 2.31, post 3.50), anesthesia overall preparedness (pre 2.75, post 4.04), otolaryngology skills (pre 2.90, post 4.19), otolaryngology scenarios (pre 2.80, post 4.00), and otolaryngology overall preparedness (pre 2.38, post 3.75). Very large effect sizes (Cohen’s d, range = 1.6-2.9) were observed. Conclusion: Changing rotation structure in ORL-HNS training programs provides an opportunity to develop novel rotations with high educational impact. Early outcome data suggest that the described clinical skills rotation is practically feasible and was perceived to have measurable value as part of the PGY-1 curriculum.

The perioperative care of adult patients undergoing free tissue transfer during head and neck surgical (microvascular) reconstruction is inconsistent across practitioners and institutions. The executive board of the Society for Head and Neck Anesthesia (SHANA) nominated specialized anesthesiologists and head and neck surgeons to an expert group, to develop expert consensus statements. The group conducted an extensive review of the literature to identify evidence and gaps and to prioritize quality improvement opportunities. This report of expert consensus statements aims to improve and standardize perioperative care in this setting. The Modified Delphi method was used to evaluate the degree of agreement with draft consensus statements. Additional discussion and collaboration was performed via video conference and electronic communication to refine expert opinions and to achieve consensus on key statements. Thirty-one statements were initially formulated, 14 statements met criteria for consensus, 9 were near consensus, and 8 did not reach criteria for consensus. The expert statements reaching consensus described considerations for preoperative assessment and optimization, airway management, perioperative monitoring, fluid management, blood management, tracheal extubation, and postoperative care. This group also examined the role for vasopressors, communication, and other quality improvement efforts. This report provides the priorities and perspectives of a group of clinical experts to help guide perioperative care and provides actionable guidance for and opportunities for improvement in the care of patients undergoing free tissue transfer for head and neck reconstruction. The lack of consensus for some areas likely reflects differing clinical experiences and a limited available evidence base.

Careful airway risk assessment and procedural planning are vital to ensure patients' safety during airway management. Patients with known procedural difficulty during previous airway management or new anatomical changes pose challenges and risks. To improve communication and the value of documented information regarding difficult airway management for future clinical encounters, we utilized existing electronic health record functions to develop a "difficult airway Navigator." We describe this tool's creation and implementation, which allows clinicians to readily review past airway information and efficiently create difficult airway notes, bedside signs, flags, and orders.

Purpose: As the COVID-19 pandemic has unfolded, there has been growing recognition of risks to the anesthesia and surgical teams that require careful consideration to ensure optimal patient care. Airway management and other head and neck procedures risk exposure to mucosal surfaces, secretions, droplets, and aerosols that may harbor the SARS-CoV-2 virus. This review provides guidance on optimal practice approaches for performing patient evaluation and management of head and neck procedures with the shared goal of providing safe and effective patient care while minimizing the risk of viral transmission. Methods: The scientific literature was evaluated, focusing on strategies to reduce risk to health care workers involved in airway management and head and neck surgery. The search strategy involved curating consensus statements and guidelines relating to COVID-19 or prior coronavirus outbreaks in relation to aerosol-generating procedures (AGPs) and other high-risk procedures, with the search restricted to the scope of head and neck anesthesia. A multidisciplinary team analyzed the findings, using iterative virtual communications through video conference, telephone, email, and shared online documents until consensus was achieved, loosely adapted from the Delphi technique. Items without consensus were so indicated or removed from the manuscript. Results: Health care worker infection and deaths during the COVID-19 pandemic and prior outbreaks mandate robust standards for infection control. Most head and neck anesthesiology procedures generate aerosols, and algorithms may be modified to mitigate risks. Examples include preoxygenation before induction of anesthesia, rapid sequence induction, closing circuits expeditiously, and consideration of apneic technique for surgical entry of airway. Rescue measures are also modified, with supraglottic airways elevated in the difficult airway algorithm to minimize the need for bag mask ventilation. Personal protective equipment for AGPs include fit-tested N95 mask (or purified air positive respirator), gloves, goggles, and gown for patients with known or suspected COVID-19. Meticulous donning and doffing technique, minimizing personnel and room traffic, diligent hand hygiene, and social distancing all can decrease risks. Perioperative management approaches may differ from commonly employed patterns including avoidance of techniques such as jet ventilation, high-flow nasal oxygen and instead utilizing techniques with a closed ventilatory circuit and secured endotracheal tube, minimizing open suctioning, and preventing aerosolization at emergence. Recommendations are made for the following head and neck procedures and considerations: primary airway management; high-flow nasal oxygen delivery; jet ventilation for laryngotracheal surgery; awake intubation; transnasal skull base surgery; tracheostomy; and use of personal protective equipment. COVID-19 testing may facilitate decision making, but it is currently often unavailable and urgency of surgical treatment must be considered. Conclusions: During pandemics, head and neck anesthesia and surgical teams have a duty to not only provide high quality patient care but also to ensure the safety of the health care team. Several specific perioperative approaches are recommended that have some variance from commonly employed practices, focusing on the reduction of AGP to minimize the risk of infection from patients with known or suspected COVID-19 infection.

Objectives/Hypothesis Local anesthetic with epinephrine is commonly injected into the nasal mucosa during functional endoscopic sinus surgery (FESS). Systemic absorption of epinephrine following local injection may occur, resulting in a mild sympathetic response. This study seeks to determine whether an exaggerated sympathetic response to epinephrine is demonstrated in patients undergoing FESS treated preoperatively with established pharmacologic beta (β) adrenoceptor blockade. Study Design A retrospective analysis of adult patients undergoing FESS at a tertiary care university hospital. Methods The primary outcome was the occurrence of an exaggerated hypertensive response within the first hour of surgical time defined by a relative increase (>20%) in the first measured intraoperative systolic blood pressure (SBP) prior to induction of anesthesia, or a single SBP value above 200 mm Hg. A mixed effects logistic regression model was developed to identify independent predictors of an exaggerated hypertensive response and describe the variance in the outcome attributable to the surgeon and anesthesiologist. Results There were 2,051 patients identified. Independent predictors of an exaggerated intraoperative hypertensive event included: preoperative β-blocker use (adjusted odds ratio [AOR]: 3.33), female gender (AOR: 1.92), body mass index (AOR: 1.03), lower baseline SBP (AOR: 0.93), and advanced age (AOR: 1.03). The C statistic for the model was 0.8881. Conclusions Preoperative β-blocker use is an independent predictor of an exaggerated hypertensive response within the first hour of operative time. An exaggerated hypertensive effect should be anticipated in patients presenting for FESS with established pharmacologic β-blockade, and caution should be applied to use of epinephrine-containing solutions. Level of Evidence 4. Laryngoscope, 127:1496–1505, 2017

BackgroundMultiple attempts at tracheal intubation are associated with mortality, and successful rescue requires a structured plan. However, there remains a paucity of data to guide the choice of intubation rescue technique after failed initial direct laryngoscopy. The authors studied a large perioperative database to determine success rates for commonly used intubation rescue techniques.MethodsUsing a retrospective, observational, comparative design, the authors analyzed records from seven academic centers within the Multicenter Perioperative Outcomes Group between 2004 and 2013. The primary outcome was the comparative success rate for five commonly used techniques to achieve successful tracheal intubation after failed direct laryngoscopy: (1) video laryngoscopy, (2) flexible fiberoptic intubation, (3) supraglottic airway as part of an exchange technique, (4) optical stylet, and (5) lighted stylet.ResultsA total of 346,861 cases were identified that involved attempted tracheal intubation. A total of 1,009 anesthesia providers managed 1,427 cases of failed direct laryngoscopy followed by subsequent intubation attempts (n = 1,619) that employed one of the five studied intubation rescue techniques. The use of video laryngoscopy resulted in a significantly higher success rate (92%; 95% CI, 90 to 93) than other techniques: supraglottic airway conduit (78%; 95% CI, 68 to 86), flexible bronchoscopic intubation (78%; 95% CI, 71 to 83), lighted stylet (77%; 95% CI, 69 to 83), and optical stylet (67%; 95% CI, 35 to 88). Providers most frequently choose video laryngoscopy (predominantly GlideScope® [Verathon, USA]) to rescue failed direct laryngoscopy (1,122/1,619; 69%), and its use has increased during the study period.ConclusionsVideo laryngoscopy is associated with a high rescue intubation success rate and is more commonly used than other rescue techniques.

Background The Mallampati examination is a standard component of an airway risk assessment. Existing evidence suggests that cervical spine extension improves the predictive power of the Mallampati examination for detecting difficult laryngoscopy and tracheal intubation, but a comparative effectiveness study has not been conducted. Methods The extended Mallampati examination (EMS) was introduced to the standard preoperative airway assessment, in addition to the standard Modified Mallampati examination (MMP). This study compared the accuracy of both Mallampati examinations on the prediction of difficult laryngoscopy, tracheal intubation, and bag mask ventilation. Univariate and adjusted analyses were performed. Results 80 801 patients with recorded MMP and EMS, and subsequent glottic view obtained during direct laryngoscopy, were examined. There was increased specificity (88.7% cf. 81.9%) but reduced sensitivity (33.3% cf. 45.7%) in the detection of difficult direct laryngoscopy with use of the EMS. The area under the receiver operating characteristic curve of each test performed in combination with other airway predictors for the models predicting difficult laryngoscopy was 0.740 (95% CI 0.731–0.753) for MMP and 0.739 (95% CI 0.729–0.752) for EMS. The area under the receiver operating characteristic curve of each test, performed in combination with other airway predictors for the models predicting difficult intubation was 0.699 (95% CI 0.688–0.711) for MMP and 0.695 (95% CI 0.683–0.707) for EMS. Conclusions This retrospective observational study demonstrates that cervical extension improves the specificity but decreases sensitivity of Mallampati examination. The Mallampati evaluation should be performed with the cervical spine in the neutral position to maximize test sensitivity.

External laryngeal trauma is a rare but potentially fatal event that presents several management challenges. This retrospective observational case series conducted at a level-1 trauma center over a 12-year period consists of 62 cases of acute external laryngeal trauma. Patient demographics, mode and mechanisms of injury, presenting signs and symptoms, initial imaging results, airway management, time to surgical management, and 6-month outcomes including airway status, deglutition status, and voice quality were investigated. No difference was found in mortality or 6-month outcomes between patients requiring surgical repair and/or tracheostomy versus patients with less severe injuries managed conservatively.

Local anesthetic with epinephrine is commonly injected into the nasal mucosa during functional endoscopic sinus surgery (FESS). Systemic absorption of epinephrine following local injection may occur, resulting in a mild sympathetic response. This study seeks to determine whether an exaggerated sympathetic response to epinephrine is demonstrated in patients undergoing FESS treated preoperatively with established pharmacologic beta (β) adrenoceptor blockade.A retrospective analysis of adult patients undergoing FESS at a tertiary care university hospital.The primary outcome was the occurrence of an exaggerated hypertensive response within the first hour of surgical time defined by a relative increase (20%) in the first measured intraoperative systolic blood pressure (SBP) prior to induction of anesthesia, or a single SBP value above 200 mm Hg. A mixed effects logistic regression model was developed to identify independent predictors of an exaggerated hypertensive response and describe the variance in the outcome attributable to the surgeon and anesthesiologist.There were 2,051 patients identified. Independent predictors of an exaggerated intraoperative hypertensive event included: preoperative β-blocker use (adjusted odds ratio [AOR]: 3.33), female gender (AOR: 1.92), body mass index (AOR: 1.03), lower baseline SBP (AOR: 0.93), and advanced age (AOR: 1.03). The C statistic for the model was 0.8881.Preoperative β-blocker use is an independent predictor of an exaggerated hypertensive response within the first hour of operative time. An exaggerated hypertensive effect should be anticipated in patients presenting for FESS with established pharmacologic β-blockade, and caution should be applied to use of epinephrine-containing solutions.4. Laryngoscope, 127:1496-1505, 2017.

Background Research regarding difficult mask ventilation (DMV) combined with difficult laryngoscopy (DL) is extremely limited even though each technique serves as a rescue for one another. Methods Four tertiary care centers participating in the Multicenter Perioperative Outcomes Group used a consistent structured patient history and airway examination and airway outcome definition. DMV was defined as grade 3 or 4 mask ventilation, and DL was defined as grade 3 or 4 laryngoscopic view or four or more intubation attempts. The primary outcome was DMV combined with DL. Patients with the primary outcome were compared to those without the primary outcome to identify predictors of DMV combined with DL using a non-parsimonious logistic regression. Results Of 492,239 cases performed at four institutions among adult patients, 176,679 included a documented face mask ventilation and laryngoscopy attempt. Six hundred ninety-eight patients experienced the primary outcome, an overall incidence of 0.40%. One patient required an emergent cricothyrotomy, 177 were intubated using direct laryngoscopy, 284 using direct laryngoscopy with bougie introducer, 163 using videolaryngoscopy, and 73 using other techniques. Independent predictors of the primary outcome included age 46 yr or more, body mass index 30 or more, male sex, Mallampati III or IV, neck mass or radiation, limited thyromental distance, sleep apnea, presence of teeth, beard, thick neck, limited cervical spine mobility, and limited jaw protrusion (c-statistic 0.84 [95% CI, 0.82-0.87]). Conclusion DMV combined with DL is an infrequent but not rare phenomenon. Most patients can be managed with the use of direct or videolaryngoscopy. An easy to use unweighted risk scale has robust discriminating capacity.

Multiple attempts at tracheal intubation are associated with mortality, and successful rescue requires a structured plan. However, there remains a paucity of data to guide the choice of intubation rescue technique after failed initial direct laryngoscopy. The authors studied a large perioperative database to determine success rates for commonly used intubation rescue techniques. Using a retrospective, observational, comparative design, the authors analyzed records from seven academic centers within the Multicenter Perioperative Outcomes Group between 2004 and 2013. The primary outcome was the comparative success rate for five commonly used techniques to achieve successful tracheal intubation after failed direct laryngoscopy: (1) video laryngoscopy, (2) flexible fiberoptic intubation, (3) supraglottic airway as part of an exchange technique, (4) optical stylet, and (5) lighted stylet. A total of 346,861 cases were identified that involved attempted tracheal intubation. A total of 1,009 anesthesia providers managed 1,427 cases of failed direct laryngoscopy followed by subsequent intubation attempts (n = 1,619) that employed one of the five studied intubation rescue techniques. The use of video laryngoscopy resulted in a significantly higher success rate (92%; 95% CI, 90 to 93) than other techniques: supraglottic airway conduit (78%; 95% CI, 68 to 86), flexible bronchoscopic intubation (78%; 95% CI, 71 to 83), lighted stylet (77%; 95% CI, 69 to 83), and optical stylet (67%; 95% CI, 35 to 88). Providers most frequently choose video laryngoscopy (predominantly GlideScope [Verathon, USA]) to rescue failed direct laryngoscopy (1,122/1,619; 69%), and its use has increased during the study period. Video laryngoscopy is associated with a high rescue intubation success rate and is more commonly used than other rescue techniques.