Anesthesia for rhinoplasty

What repeats

Five findings that hold across the literature.

General anesthesia is the usual choice, and the alternatives are not more dangerous

A systematic review of the studies published since 2000 found general anesthesia used in 72% of rhinoplasty, with local anesthesia plus sedation preferred for selected secondary and minor procedures. Complication rates did not differ significantly between the three modalities. Nausea and vomiting were the exception, reported in 12% after general anesthesia, 7% after sedation and 4% after local anesthesia alone. The randomised comparison of the two was run in septoplasty. Sixty patients of American Society of Anesthesiologists status 1 or 2 were assigned to general anaesthesia or to local anaesthesia with dexmedetomidine sedation, 30 in each arm. The sedation group bled less during surgery, recovered faster, scored lower for pain afterwards and had less nausea and vomiting.

Rests on: Barone et al., anesthesia modalities · Dogan et al., sedation against general anaesthesia.

Sedation is for a narrow group of patients

Procedural sedation for rhinoplasty is described for patients of American Society of Anesthesiologists physical status 1 or 2, with a well controlled status 3 sometimes accepted, and excludes obstructive sleep apnoea, reflux and a body mass index of 35 or above. The patient is awake enough to know what is happening and should not mind. Sedation is not general anesthesia without an airway, and an anesthetist stays with the patient throughout.

Rests on: Sklar et al., intravenous and local anesthesia.

The blood pressure is run low on purpose

Permissive hypotension means holding mean arterial pressure at 60 to 70 mm Hg so the surgeon can see the field. A review of ten studies found intraoperative bleeding and postoperative bruising and swelling all reduced when pressure was controlled, using dexmedetomidine, dexamethasone, gabapentin, labetalol, nitroglycerine, remifentanil, magnesium sulfate, clonidine or metoprolol. Head to head trials sit under that review. Dexmedetomidine against magnesium sulfate in 60 patients produced a lower bleeding score and a higher surgeon satisfaction score, at the cost of bradycardia and longer sedation. Nitroglycerine against labetalol in 60 septorhinoplasty patients held the pressure lower, with 90% of the labetalol group needing isoflurane added to reach the target, and the surgeons preferred the nitroglycerine field, while measured blood loss did not differ.

Rests on: Khetpal et al., permissive hypotension · Rokhtabnak et al., dexmedetomidine against magnesium · Ghodraty et al., labetalol against nitroglycerine.

Two drugs given around the operation change swelling, bruising and bleeding

Tranexamic acid, pooled across eleven randomised trials of 841 patients, cut blood loss by 39.37 mL, reduced swelling and bruising on the first day, and raised surgeon satisfaction with the field, with no change in operating time. Systemic corticosteroids, pooled across 336 patients in eight trials, reduced worst swelling and worst bruising and the same at one day, with no increase in bleeding during surgery. Neither effect survives to the seventh day.

Rests on: Gutierrez et al., tranexamic acid · Coroneos et al., corticosteroids · and recovery.

Waking up badly is common, and preventable

Emergence agitation after rhinoplasty was measured in 140 adults randomised to saline or a sub-anesthetic dose of ketamine given 20 minutes before the end of surgery. Agitation on extubation occurred in 54.3% of the control group and 8.6% of the ketamine group. In the recovery room it was 28.6% of controls and none of the ketamine group. Male sex, severe pain and smoking were risk factors. A nerve block does the same job. Sixty-six septorhinoplasty patients were randomised to bilateral infraorbital and infratrochlear block with 8 mL of 0.5% ropivacaine or to saline. Agitation on emergence occurred in 20.0% of the block group and 62.5% of the sham group, and fewer block patients needed tramadol afterwards, 30.0% against 65.6%.

Rests on: Demir and Yuzkat, ketamine · Choi et al., infraorbital and infratrochlear block.

By what happens at each stage

Four decisions, in the order they are made.

Before the operation

The clinical practice guideline tells the surgeon to educate the patient about strategies for managing discomfort before the operation, and to counsel patients with documented obstructive sleep apnoea about how it affects perioperative management. It also recommends against continuing antibiotics past 24 hours and against routine nasal packing.

Rests on: the clinical practice guideline · the plain language summary.

During the operation

Local anesthetic with adrenaline is injected into the lining and the soft tissue of the nose whichever anesthetic is used, because it both numbs and narrows the vessels. Nerve blocks and long-acting local anesthetic added at this stage are the intraoperative half of an opioid-sparing plan. What goes into the syringe has been tested. Adding a sub-anesthetic dose of ketamine to the lidocaine and adrenaline solution was compared with plain lidocaine and adrenaline and with saline in 90 patients randomised three ways. The ketamine group scored lowest for pain, needed no rescue analgesia, and was most satisfied at 24 hours.

Rests on: Liu et al., opioid-sparing pain control · Sanli et al., ketamine added to the infiltration · Sklar et al. · and open against closed rhinoplasty.

At the end of the operation

Packing the nose is the contested step. Reviews of the packing literature report limited benefit in reducing bleeding, swelling and bruising, and a clear cost in patient discomfort. Splints deliver similar benefit. Where packing is used, published duration runs from 24 to 72 hours. A throat pack is a separate decision from a nose pack. In 152 septorhinoplasty patients randomised to a throat pack or to none, the pack left nausea and vomiting unchanged and was followed by more sore throat early on. Nausea, vomiting and sore throat were all more common in the women.

Rests on: Caimi et al., nasal packing · Uzun et al., throat packing trial · Barone et al. · the clinical practice guideline.

After discharge

Rhinoplasty pain is mild and short. In a diary study of consecutive patients, the mean number of opioid tablets consumed was 6.15 over fourteen days and pain scores fell below 1 by the second week, with no association between the technique used and the number of tablets taken. In a separate survey, patients prescribed 10 to 40 oxycodone tablets took a mean of 5.2.

Rests on: Marshall et al., standardized regimen · Gadkaree et al., pain and satisfaction · and recovery.

What to ask about anesthesia for rhinoplasty

Questions the evidence supports asking.

Who gives the anesthetic, and where

Ask whether the operation is in a hospital, a licensed surgical centre or an office, and whether an anesthetist is present for the whole case. Sedation protocols assume a dedicated anesthetist.

Rests on: Sklar et al. · Barone et al..

Am I a candidate for sedation rather than general anesthesia

Ask about sleep apnoea, reflux and body mass index, the three exclusions named in the sedation protocol. Ask what the surgeon does if sedation is not enough during the case.

Rests on: Sklar et al. · the clinical practice guideline.

Will you use tranexamic acid and steroids

Both are supported by pooled randomised evidence for less bleeding, swelling and bruising in the first days. Ask which the surgeon uses, and ask about the reasons not to use them in a given patient.

Rests on: Gutierrez et al. · Coroneos et al..

Will my nose be packed

Ask, because the guideline recommends against routine packing and the packing reviews find limited benefit. Ask what is used instead, and when splints come out.

Rests on: the clinical practice guideline · Caimi et al. · and recovery.

What will I be sent home with

A randomised trial found ibuprofen non-inferior to hydrocodone with acetaminophen on the day of surgery and better on the first day. A standardised pathway using tramadol, celecoxib, prednisone and acetaminophen produced lower mean pain scores than traditional opioid prescribing, 3.8 against 5.9, without raising opioid use. The wider evidence points the same way. Forty-seven studies of 3717 patients, 45 of them randomised, have tested analgesia after septoplasty and rhinoplasty, and almost every intervention beat its control. Pooling 15 randomised trials of 1210 sinonasal surgery patients, non-steroidal anti-inflammatories cut pain after septorhinoplasty by 1.14 standard deviations, cut the need for rescue medication to a relative risk of 0.45 and cut nausea to 0.62, with no rise in nosebleed at 0.72.

Rests on: Frants et al., opioids against anti-inflammatories · Lee et al., meta-analysis of anti-inflammatories · Shafiee et al., systematic review of analgesia · Brownlee et al., enhanced recovery pathway · Liu et al..

The terms, defined

The words used about anesthesia for this operation.

• General anesthesia: the patient is unconscious with a protected airway, and it is the method used in most rhinoplasty. [41249522]
• Sedation with local anesthesia: drugs given intravenously to make the patient comfortable while the nose itself is numbed by injection. [24093657]
• ASA physical status: the American Society of Anesthesiologists grade of how sick a patient is, from 1 for healthy upward. [24093657]
• Local infiltration: injection of local anesthetic with adrenaline into the lining and soft tissue of the nose, for numbness and for narrowing the vessels. [37328152]
• Permissive hypotension: deliberately holding mean arterial pressure at 60 to 70 mm Hg to keep the surgical field clear. [36877227]
• Tranexamic acid: a drug that slows the breakdown of clot, given before or during surgery to reduce blood loss. [38097691]
• Emergence agitation: restlessness and disorientation on waking from general anesthesia. [29464385]
• Nasal packing: gauze or sponge placed in the nose at the end of surgery, recommended against as a routine. [38485786]

Where else this is documented

Sources outside the journals, each one free to read.

The national guideline

The American Academy of Otolaryngology guideline covers the perioperative decisions directly: what the patient is told about managing discomfort, how sleep apnoea changes the plan, how long antibiotics run, and whether the nose is packed. The plain language summary states the same points for patients.

Rests on: the clinical practice guideline · the plain language summary.

The reference summaries

• General Anesthesia for Surgeons in StatPearls, free full text on the National Library of Medicine's Bookshelf.
• Postoperative Pain Control in StatPearls, covering the multimodal regimens named above.
• Lidocaine in StatPearls, the local anesthetic injected into the nose, with dosing and toxicity.

The society page

Types of anesthesia, the American Society of Anesthesiologists' patient page, sets out what general anesthesia, sedation and local anesthesia mean.

The surgeons' own textbook chapter

A Patient's Guide to Rhinoplasty, in Rhinoplasty Archive, the free online rhinoplasty textbook edited by Daniel G. Becker, covers the day of surgery from the patient's side.

The trials in progress

Long-acting local anesthetic after rhinoplasty is under test.

• Efficacy of Liposomal Bupivacaine Post Septorhinoplasty, enrolling by invitation, 72 participants.

What is not settled

• The randomised comparison of sedation against general anaesthesia was run in septoplasty rather than rhinoplasty, at one centre, in 60 patients. The claim that complication rates match across the three modalities in rhinoplasty comes from pooling observational series. [20498606] [41249522]
• Permissive hypotension has no agreed drug. The review names nine agents, and the trials that put two of them head to head run 60 patients at a single centre each. [36877227] [29696129] [29696111]
• The tranexamic acid trials measure blood loss and surgeon satisfaction, not patient-reported recovery, and heterogeneity between them is high. [38097691]
• Corticosteroid benefit is gone by the seventh day, and no trial links the early reduction in swelling to the final shape of the nose. [26773090]
• Opioid consumption after rhinoplasty is measured in small single-centre series with diaries and pill counts. Prescribing still runs far above consumption. [32838441] [31536105] [37328152]
• Whether better pain control raises satisfaction is shown only for patients having functional surgery. In cosmetic patients no association was found. [31536105]