|Year : 2017 | Volume
| Issue : 4 | Page : 203-208
Comparison between sedation and general anesthesia for endoscopic ear surgery
Yasser Osman PhD
Department of Anesthesia and Surgical Intensive Care, Alexandria University, Alexandria, Egypt
|Date of Submission||14-Dec-2016|
|Date of Acceptance||17-Mar-2017|
|Date of Web Publication||11-Oct-2017|
Lecturer in Alexandria University, Alexandria University, Alexandria
Source of Support: None, Conflict of Interest: None
There are few published articles discussing anesthesia in patients undergoing endoscopic transcanal stapes surgery. In addition, general anesthesia carries a greater cost to the hospital and the patient’s recovery in the immediate postoperative period is more symptomatic.
This study aims to compare the effectiveness of performing endoscopic ear surgery under sedation using dexmedetomidine and under general anesthesia. The secondary aim is to identify any side effect to the sedation with dexmedetomidine.
Patients and methods
This is a prospective randomized study comparing two groups of 20 adult patients scheduled for endoscopic transcanal stapes surgery; the surgery in the first group (group I) was performed under sedation with dexmedetomidine and in the second group (group II), surgery was performed under general anesthesia. Both groups received local anesthesia to decrease postoperative pain and to minimize the bleeding.
There were no operative time differences between both groups, but time in the recovery room was significantly shorter in group I (19.7±5.4 min) in comparison with group II (30.8±7.6 min). There were no significant differences in the postoperative complaints between both groups, except for postoperative intubation sore throat, which was not found in the patients with sedation, and postoperative nausea and vomiting, which was statistically significant higher in the patients using general anesthesia 25%.
We conclude that endoscopic ear surgery may be performed with local anesthesia and sedation using dexmedetomidine in adult patients, with some advantages over general anesthesia (especially in the postoperative period faster recovery and lower incidence of nausea and vomiting), being an option at the time of surgical decision.
Keywords: dexmedetomidine, endoscopic ear surgery, sedation
|How to cite this article:|
Osman Y. Comparison between sedation and general anesthesia for endoscopic ear surgery. Res Opin Anesth Intensive Care 2017;4:203-8
| Introduction|| |
Otosclerosis is one of the most frequent causes of conductive hearing loss in adults. Surgical treatment is considered to be the gold standard for this disease. Stapes surgeries are currently performed with the aid of an operating microscope, with excellent results worldwide.
Endoscopic transcanal stapes surgery is a new approach for the treatment of conductive hearing loss because of otosclerosis that requires a bloodless field in a completely motionless patient.
There are few published articles discussing anesthesia in patients undergoing this kind of new surgery. This approach can usually be performed under general anesthesia in almost all cases as it is considered to be easier to control the blood pressure, hence resulting in less bleeding in the operation field and a completely paralyzed patient, which enables easier surgical manipulation. Patients who receive general anesthesia have longer hospital stays, greater cost, and the recovery in the immediate postoperative period is more symptomatic. Therefore, general anesthesia is not the optimal mode of anesthesia in a day case surgery such as endoscopic ear surgeries ,. Local anesthesia with some sedation would be a better choice for a day case surgery if possible.
Several agents including midazolam, ketamine, remifentanil, propofol, and dexmedetomidine have been used for this purpose.
Dexmedetomidine is a centrally acting α-2 adrenoceptor agonist that can be titrated to the desired level of sedation without causing significant respiratory depression ,,, which is a very important requirement in such operations, especially as the head is covered and rotated to one side; thus, it is difficult to manipulate the airway during surgery. Dexmedetomidine has an analgesic-sparing effect, significantly reducing opioid requirements both during and after surgery ,,. Because of its analgesic properties and lack of respiratory depression as described above, dexmedetomidine is increasingly being used as a sedative agent . However, dexmedetomidine has been shown to exert a sympatholytic effect  and has also been reported to decrease systemic blood pressure, heart rate, and cardiac output in a dose-dependent manner , which is a disadvantage in most surgical operations, but in endoscopic ear surgery, where hypotension and bradycardia are needed for a bloodless field, it is an added advantage.
| Aim|| |
This study aimed to compare the effectiveness of performing endoscopic ear surgery under sedation using dexmedetomidine and under general anesthesia. The secondary aim was to identify any side effect to the sedation with dexmedetomidine.
| Patients and methods|| |
The study protocol was reviewed and approved by the Ethics Committee of the Alexandria Main University Hospitals. The study was registered in the PACTR database under the number PACTR201410000893222. A written informed consent was obtained from all the patients who participated in the study.
Forty adult patients between 18 and 60 years of age of both sexes were categorized randomly using a computer-generated program into two groups; each group included 20 patients scheduled for endoscopic transcanal stapes surgery.
The surgery in the first group (group I) was performed under sedation and in the second group (group II), surgery was performed under general anesthesia; both groups received local anesthesia to decrease postoperative pain and to minimize the bleeding. A minimum of 20 patients were required in each group to achieve reliable statistical results.
- Any patient with known hypersensitivity to the drugs used.
- Any patient with any psychological or neurological diseases.
- Any patient with ASA physical status III and IV.
A detailed explanation of the procedure was provided to all participating patients. Then, all patients signed a written consent.
Each patient in the first group (group I) received intravenous fentanyl 1 µg/kg, dexmedetomidine 1 µg/kg bolus, followed by a continuous administration at infusion rates of 0.50 µg/kg/h and oxygen through a nasal prong at a rate of 4 l/min. During the procedure, an increased rate of dexmedetomidine infusion to 0.75 µg/kg/h was administered if the patient was irritable. If the patient remained irritable after that or there was pain or any respiratory problem or the surgeon could not continue the operation, the patient was then given general anesthesia. After sedation, local infiltration was performed with xylocaine 2% and adrenaline 1 : 100000 at the four quadrants of the canal, superficially and deep in the osteocartilaginous junction. It began with an injection of the posterosuperior area of the canal, noting the blanching coloration of the posterior wall of the external auditory canal. Thus, analgesia was already started at the canal and was therefore always continued to the point already infiltrated. Then, infiltration of the retroauricular sulks was continued forwards to the posterior canal wall. Five to eight millilitre of the solution was used for an effective local post auricular and transcanal anesthesia.
In contrast, patients in the second group received general anesthesia. Induction was carried out with intravenous fentanyl 3 µg/kg, propofol 3 mg/kg and rocuronium 0.5 mg/kg. After complete muscle relaxation, all patents were intubated using a proper endotracheal tube. After anesthesia, local infiltration with xylocaine 2% and adrenaline 1 : 100000 was performed in the same manner. Anesthesia was maintained with isoflurane1.5–2% and rocuronium top-up doses when needed. Prostigmine 2.5 mg and atropine 1 mg were administered in reverse at the end of the operation after discontinuation of isoflurane. Ondansetron 4 mg and metoclopramide 10 mg were administered to all patients.
In any group, if any additional steps were needed to achieve a bloodless field such as addition of drugs for hypotensive anesthesia or decrease the heart rate or increase the depth of anesthesia, the technique was considered to be a failure and the patient was excluded from the research and the event was noted.
The surgical technique was the same in both groups. All surgical steps were followed and completed irrespective of the type of anesthesia. This type of surgery is a single-handed surgery in which one hand holds the endoscope to visualize the surgical field and the other handles the surgical instruments. Thus, it is of a paramount importance to have a bloodless field to avoid excessive suction of blood and inner ear fluid after performing fenestration of the footplate, and consequently facilitates prosthesis insertion and decreases the risk of sensorineural deafness.
Surgical time, time in the recovery room, length of hospital stay, postoperative symptoms (pain, nausea, vomiting, dizziness), and the degree of patient satisfaction with surgery and anesthesia were determined.
In addition, patients were asked whether they would undergo the surgery again with the same type of anesthesia, and the immediate postoperative pain was also evaluated using a visual analog scale.
Vital signs including pulse rate, non invasive blood pressure, and oxygen saturation were monitored and determined regularly during the operation.
Statistical analysis was carried out using the SPSS program for Windows, version 17.0 (SPSS Inc., Chicago, Illinois, USA).
To analyze the data obtained, we used a t-test. Values were considered statistically significant if P value of less than 0.05.
| Results|| |
All 40 patients who were enrolled in the study completed the study protocol and were included in the data analysis.
Demographic data did not differ among the two study groups ([Table 1]).
By comparing the surgical time between both groups, 1.38±0.15 hours in group I and 1.39±0.17 in group II, with a P value of 0.84, it was found that there was no statistical difference between both the groups; however, the time in the recovery room was significantly shorter in group I, 19.7±5.4 min, in comparison with group II, 30.8±7.6 min, with a P value of 0.00002. Also, the length of hospital stay was significantly shorter in group I, 2.3±0.5 h, compared with 5.1±0.7 h, with a P value of 0.000003.
The numbers of patients excluded from the study were as follows: two patients were excluded from group II (general anesthesia group) because of the need for addition of a hypotensive drug and four patients because of the need to increase the depth of anesthesia to control the bleeding, total 26%; in contrast, only one patient was excluded from group I 4% because of the need to convert to general anesthesia as the patient was irritable. There was a statistical difference in the number of patients excluded from the study.
There were no significant differences in the postoperative complaints between both groups, except for postoperative intubation sore throat, which was not found in the patients with sedation, and postoperative nausea and vomiting, which was statistically significantly higher in the patients using general anesthesia. Twenty-five percentage (five patients) of the patients in group II complained of some sort of nausea in the postoperative period in comparison with only 5% (one patient) in group I.
Pain reported by patients in the immediate postoperative period was assessed using the visual analog scale graded from 0 to 10 (0 no pain felt and 10 maximal pain). There was no pain (grade 0) in the early hours in all patients of both groups. Patients were asked whether they would undergo the surgery again with the same anesthesia, and all responded positively; thus, the degree of subjective satisfaction of patients with anesthesia was similar in both groups.
The surgeon was asked about the degree of bleeding, the visualization of the surgical field by the endoscope, and patient movement.
No difference was noted by the surgeon between both groups, although he reported being more at ease using sedation for his patients ([Figure 1],[Figure 2],[Figure 3]).
There was no statistical difference in vital signs (mean arterial blood pressure pulse rate and oxygen saturation) between both groups.
| Discussion|| |
Endoscopic ear surgery is a new surgical technique that facilitates surgery and shortens the time of operation. This makes ear surgery more suitable as a day case surgery. This surgery is performed under general anesthesia; thus, we carried out this study to determine whether it is possible to perform endoscopic ear surgery under local anesthesia with sedation using dexmedetomidine, making the surgery simple and more suitable as a day case surgery, without the complications of general anesthesia.
Jourdy and Kacker  reported the effectiveness of local anesthesia and sedation for otologic surgeries.
Bailey et al.  raised the question of the safety of sedation using midazolam and fentanyl and the frequent hypoxemia and apnea associated with it.
Also, Alhashemi  proved that dexmedetomidine, compared with midazolam, does not appear to be suitable for sedation in patients undergoing cataract surgery as it was accompanied by relative cardiovascular depression and delayed recovery room discharge.
Although ear surgeries can be performed under local anesthesia, endoscopic ear surgery is a highly specialized kind of surgery as a bloodless field is needed in addition to minimal movement, and the surgery involves fine manipulation and handling of the endoscope with one hand.
All of these aspects raised some doubts in terms of performing such an operation under local anesthesia and sedation. Numerous sedative drugs are used such as midazolam, ketamine, diazepam, and dexmedetomidine. The latter drug has been used as an adjuvant for general anesthesia, but there is very little literature on its use as the sole sedative drug.
Local anesthesia in ear surgeries requires familiarity with the anatomy and physiology of that organ . The drugs used by anesthesiologists for sedation are well established according to Chakrabarty et al. . An experienced anesthesiologist is fundamental to control the doses used and providing supplementary doses as needed ,.
On comparing the surgical durations between both groups in this study, we found no statistical difference; this proves that the sedation technique used did not affect the surgical manipulations or hinder it in any way. The surgeon also confirmed this. There were no complaints of bleeding or excessive movement in the patients who underwent the surgery.
Six patients were excluded from group II (general anesthesia group), 26%, because of the need to add a hypotensive drug or increase the depth of anesthesia to control the bleeding; in contrast, only one patient was excluded from group I, 4%, as the patient was irritable and was converted to general anesthesia. The statistically significant difference between the two groups suggests that dexmedetomidine, when used for sedation, also exerts beneficial hypotensive effects and helps control the hemodynamics, leading to less bleeding at the site of the operation, and is better than the use of just general anesthesia.
However, there was a statistical difference in the time of recovery in the recovery room and also in the total hospital stay of the patient; this makes the sedation technique more suitable and economical to use in the day case unit.
Another point of comparison was the vital signs, especially the blood pressure and the pulse rate, as it is very important to have a low blood pressure and pulse rate to prevent excessive bleeding.
On comparing the findings, there were no statistical differences between both groups in the vital signs; thus, we can conclude that this process of good local block and sedation is as good as general anesthesia in preventing sympathetic stimulation from pain or anxiety and this will provide us with the same bloodless field.
The question of having an open airway was raised as the operation is performed in the ear and the head of the patient is covered and facing one side. This concern was eliminated when we found that there was no statistical difference between both groups in oxygen saturation or any incidence of airway obstruction throughout the operation.
In terms of complications, sedation techniques did not lead to complications of general anesthesia, especially sore throat, which was significantly present in the second group, enabling early discharge with a larger safety margin. The incidence of postoperative nausea and vomiting was statistically lower in the sedation group; this may be because of the absence of the effect of intubation and inhaled anesthetics.
Another point of comparison was postoperative pain, which was statistically insignificant in both groups; this may be because of the use of the same method of local block in both groups, which acts as an excellent pre-emptive analgesia and blocks pain perception during the operation and leads to good postoperative analgesia as well. Also, it also helps provide an excellent bloodless field.
These findings were in agreement with many other papers that have discussed the use of local anesthesia in middle-ear surgery with or without sedation.
In 2013, Neumann et al.  performed mastoid surgery under local anesthesia in patients who were unfit for general anesthesia and concluded that cholesteatoma surgery can be performed successfully with a local anesthetic in patients who are medically unfit for general anesthesia. Surgery requires a good coordination of the operating team to shorten the operating time. Unlike the present study, Neumann et al.  used no sedation and needed a speedy surgery to insure patient comfort.
Caner et al.  tested the adequacy of anesthesia and comfort during surgery for 100 consecutive patients undergoing middle-ear surgery using local anesthesia, according to both the patients themselves and the surgeon. Both the surgeon and the majority of patients were satisfied with the quality of anesthesia and little adverse effects occurred as a consequence of local anesthesia itself. This finding was in agreement with the present study as most of the patients preferred the sedation and local anesthesia and the surgeons did not have any complaints .
Edussuriya et al.  and Andreassen and Larsen  also performed similar tests, and all concluded that conventional middle-ear surgeries can be performed safely under local anesthesia with sedation and that it is more economical and leads to better recovery and shorter hospital stay than procedures performed under general anesthesia.
By revising the literature and the work of Presutti et al. , Kakehata et al. , Sajjadi , and Pothier , it was clear that the most common anesthetic technique used to perform the surgery was general anesthesia as it allows the anesthetist to perform hypotensive anesthesia, thus decreasing bleeding and preventing the patient from moving, but the use of Dexmedetomidine for sedation in the present study proved that local anesthesia with sedation can be as efficient as general anesthesia and can avoid the drawbacks of some sedatives such as midazolam. Midazolam can cause respiratory embarrassment if deep sedation occurs as proven by Bailey et al. .
| Conclusion|| |
Eendoscopic ear surgery may be performed with local anesthesia and sedation using dexmedetomidine in adult patients, with some advantages over general anesthesia, being an option at the time of surgical decision.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]