What Enhanced Recovery After Surgery Protocols Mean for Otolaryngology

In an interview with ENTtoday, Adam Levine, MD, professor of anesthesiology, perioperative and pain medicine, otolaryngology, and pharmacological sciences at the Icahn School of Medicine at Mount Sinai in New York, NY, discussed some of the advances being made in otolaryngology anesthesia and ERAS protocols.

“I think the biggest innovation we’ve introduced is the use of regional anesthesia for head and neck patients. This has allowed us to perform anesthetic techniques that are opioid sparing, avoiding the intra- and postoperative use of long-acting opioids. When we use regional techniques, we have reduced levels of nausea and vomiting, lower opioid usage, and lower utilization of the post-acute care unit [PACU].”

According to Dr. Levine, who teaches workshops across the country, the head and neck region is innervated with a significant number of nerves. Although these innervations are complex, many of the nerves exit the skull, where landmarks are easy to identify without ultrasound, making them ideal candidates for regional blocks.

One example of a regional block technique is the sphenopalatine ganglion block. “We routinely perform a transoral approach to place the sphenopalatine nerve blocks,” noted Dr. Levine. “We perform the block post induction and endotracheal intubation—using an injection of 1.5 mL of 1% to 2% lidocaine with 1:100,000 of epinephrine. The epinephrine that is added to the local anesthetic helps both to decrease absorption in the area as well as improve the surgical field by reducing bleeding.” For most head and neck procedures, “we no longer utilize neuromuscular blockade,” he added.

For thyroid and parathyroid procedures, regional anesthesia techniques have allowed Dr. Levine to send patients home the day of surgery. “I really think that use of regional blocks and short-acting opioids intraoperatively expedites recovery—patients wake up, get moving, and get on with their lives without worrying about pain,” Dr. Levine said.

“I think the gestalt of ERAS for anesthesiology is to use the smallest anesthetic footprint we can possibly use—avoiding long-acting pharmacologic agents—and break the need or requirement for opioids.”—NK