http://oto.sagepub.com/Otolaryngology -- Head and Neck Surgery

http://oto.sagepub.com/content/133/2/295The online version of this article can be found at:

DOI: 10.1016/j.otohns.2004.09.112 2005 133: 295Otolaryngology -- Head and Neck Surgery

Gl Caner, Levent Olgun, Grol Gltekin and Levent AydarLocal Anesthesia for Middle Ear Surgery

Published by:

http://www.sagepublications.com

On behalf of:

American Academy of Otolaryngology- Head and Neck Surgery

can be found at:Otolaryngology -- Head and Neck SurgeryAdditional services and information for

http://oto.sagepub.com/cgi/alertsEmail Alerts:

http://oto.sagepub.com/subscriptionsSubscriptions:

http://www.sagepub.com/journalsReprints.navReprints:

http://www.sagepub.com/journalsPermissions.navPermissions:

What is This?

- Aug 1, 2005Version of Record >>

at COPYRIGHT CLEARANCE CENTER on April 24, 2013oto.sagepub.comDownloaded from

Local Anesthesia for Middle Ear Surgery

Gl Caner, MD, Levent Olgun, MD, Grol Gltekin, MD, andLevent Aydar, MD, Bozyaka-Izmir, Turkey

The adequacy of anesthesia and comfort during surgery was assessedfor 100 consecutive patients undergoing middle ear surgery usinglocal anesthesia, both by the patients themselves and by the surgeon.The possibility of inducing an iatrogenic facial weakness was alsoevaluated. Both the surgeon and the majority of patients were pleasedwith the quality of anesthesia and little adverse effects occured as aconsequence of local anesthesia itself. 2005 American Academy of OtolaryngologyHead and Neck Sur-gery Foundation, Inc. All rights reserved.

Operating without pain is a fancy which human sensescannot pursue. This fancy in the pessimistic opinion ofVelpeau in 1839 has left its place today for more complexproblems. Every new technique and drug in anesthesia is moreeffective and less toxic than the previous one, increasing thesafety of general anesthesia so that many otologic surgeonsnow prefer it for the majority of operations. General anesthesiaand local anesthesia each have advantages. Some surgeonsbelieve that patients may not tolerate the otologic interventionunder local anesthesia. Local anesthesia allows the anestheticcapacity to be employed for other major operations, may resultin slightly less bleeding and allows hearing to be tested duringsurgery.

In this prospective study, data collected by means of aquestionnaire from 100 patients undergoing middle ear sur-gery under local anesthesia and sedation were reviewed. Inaddition, the surgeon was asked for the adequacy of anes-thesia, discomfort during surgery, and postoperative tran-sient facial weakness.

MATERIALS AND METHODS

A prospective evaluation of 100 patients, 31 men and 69women, who were operated under local anesthesia in SSK

Izmir Hospital ENT Clinic for middle ear disease was un-dertaken. The mean age of the patients was 27.8 years, witha range of 13 to 55 years.

One-half hour before the patient was taken to surgery, theyreceived 50 mg of pethidine hydrochlorure and 0.5 mg ofatropine by intramuscular injection. If the patient was stillcomprehensive when placed on the operating table, additionalsedation of 5 to 10 mg of diazepam intravenously was givenbefore the patient became agitated. In the absence of inam-mation, mastoid bone is devoid of sensation except for its outerperiosteum and, to a lesser degree, its inner mucoperiosteum.Very satisfactory complete local anesthesia can be securedusing a commercially available solution containing 2% lido-caine with 1:10000 epinephrine for inltration.

Local inltration for the postauricular and the endauralincisions is as follows: the tympanic branch of the auricu-lotemporal nerve is blocked by injection of 1 or 2 mL ofsolution into the anterior meatal wall at the osteocartilagi-nous junction. The branches of the great auricular nerve tothe auricle and the meatus are blocked by injections atseveral points behind the auricle and over the mastoid pro-cess. The auricular branch of the vagus nerve is blockedinjection of the periosteum at the anterior surface of themastoid process and the skin of the oor of the meatus. Forendomeatal incisions in stapes surgery, solution is injectedto the posterior meatal wall so as not to cause a bleb. Atapproximately the same depth, approximately 0.2 mL ofsolution is then injected into the anterior, superior, andinferior meatal wall.1

In the early postoperative period, patients were askedto score their discomfort for pain, noise, anxiety, irrita-bility (uneasiness), and position of the body and neck bymeans of a questionnaire. The scores ranged from 0 to4 for each question, 0 for no discomfort and 4for extreme discomfort. In addition, the surgeon wasasked for the adequacy of anesthesia, discomfort during

From SSK Izmir Education Hospital, Bozyaka-Izmir, Turkey.Presented at the 21st Meeting of the Politzer Society, Antalya, Turkey,

1998.

Reprint requests: Gl Caner, 125 sok No:4/5, 35050 Bornova-Izmir,Turkey.

E-mail address: gulc@isbank.net.tr.

OtolaryngologyHead and Neck Surgery (2005) 133, 295-297

0194-5998/$30.00 2005 American Academy of OtolaryngologyHead and Neck Surgery Foundation, Inc. All rights reserved.doi:10.1016/j.otohns.2004.09.112

at COPYRIGHT CLEARANCE CENTER on April 24, 2013oto.sagepub.comDownloaded from

surgery, and postoperative transient facial palsy. Addi-tional questions were asked about the most disturbingsensation during the operation and whether they wouldprefer local anesthesia for a second procedure.

RESULTS

Of the patients, 11 underwent stapes surgery, myringoplastywas performed in 8 patients, and tympanoplasty was per-formed in 69 patients. Of the patients, 10 underwent tym-panoplasty and mastoidectomy; 6 of these were canal-wall-down and 4 were canal-wall-up procedures. Radicalmastoidectomy was mandatory in 2 patients. The operationwas terminated in 1 patient because of claustrophobia. Thispatient underwent stapedotomy later under general anesthe-sia.

Of the patients, 38 had a history of surgery under localanesthesia for ENT or other diseases, 11 patients werepreviously operated under general anesthesia for differentdiseases, 1 had had both local and general anesthesia, and50 patients had no history of surgery.

The number of incisions for entrance to the temporalbone was 82 retroauricular, 6 endaural, and 11 transcanal.The average time of stay on the operation table was 72minutes. The average total amount of lidocaine with epi-nephrine injected was 7.3 cc. Of the patients, 24 neededadditional medication, diazepam IV, for their increasinganxiety.

Patients scored their distress for pain with a mainvalue of 0.94. The mean score was 1.11 for anxiety, 0.96for sensation of noise during surgery, and 1.19 for irri-tability. Of the patients, 23 complained of backache.From the surgeons point of view, mean value of scoresfor anxiety was 1.46 and for irritability 1.28 (Table 1).One patient had a transient facial weakness. The majority(96%) of patients undergoing stapes surgery or tympa-noplasty without mastoidectomy noted that they had nopain during surgery. The most distressing sensation forthis group of patients was the noise caused by the instru-ments.

The most distressing sensation during surgery was anx-iety for 44 of the patients. Noise was the greatest discomfortfor 33 patients and pain was distressing for 22 of them. In

spite of these discomforts, 73 patients still preferred localanesthesia for a similar operation.

DISCUSSION

Although it has long been known that middle ear sur-gery can be carried out under local anesthesia, manysurgeons prefer local anesthesia. Less bleeding, cost-effectiveness, postoperative analgesia, mobilizationof the patient in a short time, reduced aspiration riskbecause of normal cough reex, release of anestheticcapacity for other major procedures, and that the hearingcan be tested during surgery are the advantages of localanesthesia. Preoperative sedation and local anesthesiaallows the patient to undergo a comfortable procedure.

Sensation of pain is related to personal psychologicalstatus and previous experiences. Personal variations aremore important than the degree of surgical trauma. Patientsshould be assessed meticulously by the experienced surgeonso that local anesthesia is not to be performed in unsuitablepatients. The less the patient is informed, the greater his orher anxiety will be.

Yung2 reported that although the intense sensation ofnoise and anxiety were the most common discomforts, themajority of patients preferred local anesthesia. Lancer andFisch3 and Andreassen and Larson4 have reported no ad-verse effects in their 2 different studies on local anesthesiafor middle ear surgery.

In our questionnaire survey, patients scored their dis-comfort of pain as a mean value of 0.94 corresponding toa value lower than 1, indicating means mild. Mostpatients noted that they felt pain only at the beginning ofthe surgery because of numerous injections of the localanesthetic. Beause the maximum discomfort from any ofthe sensations during the procedure was scored by 4,the mean values for anxiety (1.11), noise (0.96), andirritability (1.19) are acceptable and not importantenough to decide to abandon local anesthesia for middleear surgery. In rating the most disturbing sensation, 44%of patients complained mostly of their irritability, 33%complained of the noise during the procedure, and 22%complained of their anxiety.

The choice of patients in favor of local anesthesia fora similar procedure in spite of these discomforts hasvarious reasons. Mobilization of the patient in a shorttime, little pain in early postoperative period and thechance of being informed by the surgeon during theprocedure are the most common reasons. In highly anx-ious and less-educated patients, fear of not waking upagain after general anesthesia may be another reason forpreferring local anesthesia.

From the surgeons point of view, the ability to testhearing during surgery and less bleeding are the most strik-ing advantages. Transient facial weakness lasted no longerthan 1 hour in our series and can be overcome by injecting

Table 1Scores for complaints both by patients and thesurgeon

0 1 2 3 4Meanvalue

Surgeonsmean

Anxiety 44 10 28 12 6 1.11 1.46Pain 42 44 11 2 1 0.94 Noise 50 19 18 7 6 0.96 Irritability 32 28 26 13 1 1.19 1.28

296 OtolaryngologyHead and Neck Surgery, Vol 133, No 2, August 2005

at COPYRIGHT CLEARANCE CENTER on April 24, 2013oto.sagepub.comDownloaded from

the solution meticulously especially in the inferior meatalwall.

Our choice for local anesthesia for middle ear surgeryis especially for ears for which a stapedotomy or tympa-noplasty is to be performed. As all ENT surgeons know,the situation may differ from the preoperative examina-tion, when the tympanic cavity or mastoid cavity is en-tered and a canal-wall-down procedure or a radical mas-toidectomy can be necessary. Nevertheless, localanesthesia allows us an increased capacity of the operat-ing room that means a closer time of appointment for thepatient.

CONCLUSIONS

Middle ear surgery under local anesthesia is safe and fea-sible. It causes less bleeding and is well tolerated both by

patients and by the surgeon. Good patient selection andadequate selection are the important factors for the successof local anesthesia. The majority of patients still prefer localanesthesia for a similar procedure in the future.

REFERENCES

1. Glasscock ME III, Shambaugh GE Jr. Surgery of the ear, 4th edition.Philadelphia: WB Saunders Company; 1990.

2. Yung MW. Local anesthesia in middle ear surgery: survey of patientsand surgeons. Clin Otolaryngol 1996;21:4048.

3. Lancer JM, Fisch U. Local anesthesia for middle ear surgery. ClinOtolaryngol 1988;13:36774.

4. Andreassen UK, Larsen CB. [Anesthesia in ear surgery. A sourceeconomical analysis and patient assessment of general anesthesia versuslocal anesthesia in ear surgery]. Ugeskr Laeger 1990;28;152:15957.

297Caner et al Local Anesthesia for Middle Ear Surgery

at COPYRIGHT CLEARANCE CENTER on April 24, 2013oto.sagepub.comDownloaded from

/ColorImageDict > /JPEG2000ColorACSImageDict > /JPEG2000ColorImageDict > /AntiAliasGrayImages false /CropGrayImages true /GrayImageMinResolution 300 /GrayImageMinResolutionPolicy /OK /DownsampleGrayImages true /GrayImageDownsampleType /Average /GrayImageResolution 150 /GrayImageDepth -1 /GrayImageMinDownsampleDepth 2 /GrayImageDownsampleThreshold 1.50000 /EncodeGrayImages true /GrayImageFilter /DCTEncode /AutoFilterGrayImages true /GrayImageAutoFilterStrategy /JPEG /GrayACSImageDict > /GrayImageDict > /JPEG2000GrayACSImageDict > /JPEG2000GrayImageDict > /AntiAliasMonoImages false /CropMonoImages true /MonoImageMinResolution 1200 /MonoImageMinResolutionPolicy /OK /DownsampleMonoImages true /MonoImageDownsampleType /Average /MonoImageResolution 300 /MonoImageDepth -1 /MonoImageDownsampleThreshold 1.50000 /EncodeMonoImages true /MonoImageFilter /CCITTFaxEncode /MonoImageDict > /AllowPSXObjects false /CheckCompliance [ /None ] /PDFX1aCheck false /PDFX3Check false /PDFXCompliantPDFOnly false /PDFXNoTrimBoxError true /PDFXTrimBoxToMediaBoxOffset [ 0.00000 0.00000 0.00000 0.00000 ] /PDFXSetBleedBoxToMediaBox true /PDFXBleedBoxToTrimBoxOffset [ 0.00000 0.00000 0.00000 0.00000 ] /PDFXOutputIntentProfile (None) /PDFXOutputConditionIdentifier () /PDFXOutputCondition () /PDFXRegistryName () /PDFXTrapped /False

/CreateJDFFile false /Description > /Namespace [ (Adobe) (Common) (1.0) ] /OtherNamespaces [ > /FormElements false /GenerateStructure false /IncludeBookmarks false /IncludeHyperlinks false /IncludeInteractive false /IncludeLayers false /IncludeProfiles false /MultimediaHandling /UseObjectSettings /Namespace [ (Adobe) (CreativeSuite) (2.0) ] /PDFXOutputIntentProfileSelector /DocumentCMYK /PreserveEditing true /UntaggedCMYKHandling /LeaveUntagged /UntaggedRGBHandling /UseDocumentProfile /UseDocumentBleed false >> ]>> setdistillerparams> setpagedevice