INDONESIAN JOURNAL OF ANESTHESIOLOGY AND REANIMATION

Volume 4 (2), July 2022: 98-106

Original Article

ANESTHESIA AND ANALGESIA MANAGEMENT PROFILE FOR AIRWAY

SURGERIES AT DR. SOETOMO GENERAL ACADEMIC HOSPITAL
SURABAYA

Agustina Salinding1,3a , Widiartha Wahyudi1 , Arya Pradipta2

1 Department of Anesthesiology and Reanimation, Faculty of Medicine, Universitas Airlangga, Surabaya, Indonesia
2 Facultyof Medicine, Universitas Airlangga, Surabaya, Indonesia
3 Siloam Hospital, Surabaya, Indonesia

a Corresponding author: tiensanest@gmail.com

ABSTRACT
Introduction: Ear, Nose, and Throat (ENT) surgeries are commonly performed and very often require the surgeon and
anesthesiologist to share the same workspace. Over the years, ENT surgery techniques have evolved from conventional
methods to computer-assisted intraoperative navigation. In contrast to the past, a minimally invasive approach to paranasal
sinus and petrous bone surgery is now preferred. Bleeding, postoperative nausea, and vomiting are complications often
encountered in ENT surgery. In addition, pain management during surgery and patient comfort after a surgical procedure
is a challenge for anesthesiologists. Therefore, the choice of anesthetic drugs is important. Objective: This study aims to
determine the action profile, anesthetic management, and pain management in ENT surgery at Dr. Soetomo General
Academic Hospital Surabaya. Materials and Methods: This is a retrospective descriptive study. A total of 177 patients
underwent airway surgery. Data were obtained from the Medical Records of the Integrated Surgery Center of Dr. Soetomo
General Academic Hospital recorded from January to December 2021. Results and Discussion: Most of the patients were
in the age group of 45 - 65 years (40.1%) and a majority were men (65.5%). Most patients who were ≥ 20 years old had a
normal nutritional status (54.2%). The most frequent diagnosis was laryngeal cancer (23%), with micro laryngeal surgery
being the most frequently performed (35.8%). Most surgeries also needed less than 60 minutes followed by 60 to 119
minutes (27.1%). The most frequently used induction agents were a combination of propofol, fentanyl, and rocuronium
(39.5%), with isoflurane as the most frequent inhalation agent (91.3%). Metamizole (70.1%) was the most postoperative
analgesic. Conclusion: In general, intravenous agents were used for anesthesia induction. A combination of different
induction agents brings synergistic benefits.

Keywords: Airway; Analgesic; Anesthesia; ENT Surgery; Good Health

ABSTRAK
Pendahuluan: Pembedahan telinga, hidung, dan tenggorokan (THT) merupakan salah satu tindakan pembedahan yang
paling seringkali dilakukan dan seringkali mengharuskan ahli bedah dan tim anestesi berbagi area kerja yang sama. Teknik
pembedahan THT sekarang telah banyak berkembang mulai dari teknik konvensional hingga penggunaan bantuan
komputer dalam pelaksanaan operasi. Berbeda dengan masa lalu, saat ini tindakan invasif minimal pada operasi sinus
paranasal dan tulang petrosa lebih disukai. Adanya perdarahan serta terjadinya mual muntah pasca operasi adalah
komplikasi yang sering terjadi pada operasi THT. Karena itu, sangatlah diperlukan pemilihan obat anestesi yang tepat.
Sebagai tambahan, tata laksana nyeri selama operasi dan kenyamanan pasien setelah operasi adalah tantangan bagi ahli
anetsi. Tujuan: Penelitian ini bertujuan untuk mengetahui Profil Tindakan, manajemen anestesi dan manajemen nyeri
pada Operasti THT di RSUD Dr. Soetomo Surabaya. Bahan dan Metode: Penelitian ini merupakan penelitian deskriptif
retrospektif. Sejumlah 177 pasien menjalani operasi jalan nafas. Data diperoleh dari rekam medis pada pembedahan pusat
terpadu RSUD Dr. Soetomo, diambil bulan Januari – Desember 2021 dan dianalisis dengan aplikasi SPSS. Hasil dan
Pembahasan: Jumlah pasien terbanyak berasal dari kelompok umur 45 – 65 tahun (40,1%). Penderita laki – laki lebih
banyak dibandingkan penderita wanita (65,5%). Kebanyakan pasien berusa lebih dari 20 tahun berada dalam status nutrisi
normal (54,2%). Diagnosa terbanyak adalah kanker laring (23%), dengan tindakan pembedahan paling banyak
pembedahan bedah mikro laring (BLM) (35,8%). Sebagian besar pembedahan membutuhkan waktu kurang dari 60 menit

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dan diantara 60 – 119 menit (27,1%). Obat induksi terbanyak adalah kombinasi dari propofol, fenatnil, dan rokuronium
(39,5%), dan obat inhalasi terbanyak adalah isofluran (91,3%). Analgetik pasca operasi paling banyak menggunakan
metamizol (70,1%). Kesimpulan: Induksi anestesi umumnya secara intravena. Adanya kombinasi obat induksi
memberikan keuntungan secara sinergis.

Kata Kunci: Jalan Napas; Analgesik; Anestesi; Operasi THT; Kesehatan

Article info: Received June 10th 2022, Revised June 13th 2022, Accepted July 18th 2022, Published July 28th 2022

INTRODUCTION interventions. Tonsillectomies in particular

A total of 210 patients underwent have the potential for life-threatening bleeding.
rhinoplasty between June 2017 and December Bleeding during ENT surgery can interfere
2017 at the Konyang University Hospital, with the operative field of view and the airway,
Daejon, Korea (1). Meanwhile, at the Santo increase technical difficulties, as well as
Spirito Hospital, Casale Monferrato, Italy, increase the operating time (5). In addition,
1321 patients underwent ENT surgery between Postoperative Nausea Vomiting (PONV)
January 2002 and December 2004. In addition, occurs in 70% of patients who underwent ENT
1133 (85.7%) of them underwent airway surgery (6). PONV can cause psychological
surgery (2). effects, airway obstruction, prolongation of
Ear, Nose, and Throat (ENT) surgery is the hospitalization, and increased costs (6,7).
most common surgery performed and very Therefore, choosing the right anesthetic drug is
often requires the surgeon and anesthesiologist important.
to share the same workspace (3). There is a Ear-nose-throat (ENT) and head and neck
wide variety of existing ENT cases in various surgical procedures are unique because the
parts of the world with varying incidences. anesthesiologist and operator share an airway.
ENT surgery techniques have evolved Anesthesia management in the patient is
from conventional methods to computer- centered on the airway. Good cooperation and
assisted intraoperative navigation. In communication between the operator and the
conventional surgeries, the surgeon must apply anesthesiologist are also important for
his anatomical knowledge and experience to achieving patient safety and recovery. In
map the patient during surgery. Therefore, the addition, pain management during surgery and
radiological image must remain in the sight of patient comfort after a surgical procedure is a
the surgeon to help them determine the exact challenge for anesthesiologists.
location of the surgical instrument. This is done This study aims to determine the action
through distorted endoscopic images, with the profile, anesthetic management, and pain
possibility of bleeding and other significant management during ENT surgeries at Dr.
changes in the patient's anatomy during the Soetomo General Academic Hospital,
surgery. In contrast to the past, a minimally Surabaya.
invasive approach to the paranasal sinus and
petrous bone surgery is now preferred due to MATERIALS AND METHODS
the length of stay and patient compliance (4). This is a retrospective descriptive study.
Bleeding is a significant complication of All patients who underwent airway surgery
ENT surgery, especially in oral and nasal were included. Data on age, gender, nutritional

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status, disease, treatment, analgesic, and Diagnosis

anesthetic agents were collected. The most common diagnosis found in
Patient data were taken from the Medical patients with airway procedures was laryngeal
Records of the Integrated Surgery Center of Dr. cancer (23%).
Soetomo General Academic Hospital,
Surabaya recorded from January to December Table 2. The Most Common Patient Diagnosis
2021. The data were then processed Diagnosis N %
Juvenile Nasopharyngeal Angiofibroma 8 4.5
descriptively using the SPSS application to Laryngeal Cancer 41 23
obtain the frequency and percentage of the data. Sinonasal Cancer 12 6.7
Midline paralysis + post tracheotomy 8 4.5
SSR without polyps + deviated septum 10 5.6
RESULTS AND DISCUSSION Oropharyngeal tumor + impending UAO 9 5
Patients’ Basic Characteristics
A total of 177 patients underwent airway Surgery
surgery. There were more male patients The most frequent procedure was micro-
(65.5%) than female patients. A majority of the laryngeal surgery (24%), followed by
patients were within the 45-65 years (40.1%) Functional Endoscopic Sinus Surgery (FESS)
age group. Most patients’ nutritional status was at 17.0%.
also within normal limits for > 20 years
Table 3. The Most Frequent Surgeries
Table 1. Patients’ Characteristics Surgeries N %
Characteristics N (%) Micro Laryngeal 42 24
Gender Extirpation 9 5
Man 116 (65.5) FESS 30 17
Woman 61 (34.5) MM – RL 10 5.6
Age Group Total Laryngectomy 15 8.5
0 – 5 years 2 (1.1)
6 – 19 years 25 (14.1)
20 – 44 years 63 (35.6) Operation Duration
45 – 65 years 71 (40.1) The duration of most airway operations is
>65 years 16 (9.1)
Nutritional Status by Age Group under 60 minutes and between 60 to 119
0 – 5 years minutes (27.1%).
Severe thinness (<-3SD) 0 (0)
Thinness (-2SD - -3SD) 0 (0)
Normal (+2SD - -2SD) 0 (0) Table 4. Duration of Operations
Overweight (>+2SD - +3SD) 1(0.6) Operation Duration N (%)
Obesity (>+3SD) 1(0.6) <60 minutes 48 (27.1)
6 – 19 years 69 – 119 minutes 48 (27.1)
Severe thinness (<-3SD) 1 (0.6) 120 – 179 minutes 40 (22.6)
Thinness (-2SD - -3SD) 5 (2.8) 180 – 239 minutes 23 (13.0)
Normal (+2SD - -2SD) 22 (12.4) >240 minutes 18 (10.2)
Overweight (>+2SD - +3SD) 3 (1.7)
Obesity (>+3SD) 3 (1.7)
> 20 years Induction and Inhalation Agent
Underweight (<18.5) 2 (1.1) The most frequently used induction agent
Normal (18.5 – 24.9) 96 (54.2)
Overweight (25 – 29.9) 31 (17.5) was a combination of propofol, fentanyl, and
Obesity Class I (30 – 34.9) 10 (5.7) rocuronium (39.6%), followed by a
Obesity Class II (35 – 39.9) 2 (1.1)
combination of propofol, fentanyl, and
Obesity Class III (> 40) 0 (0)

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atracurium (37.8%). The most used inhalation steadily after the age of 35 years (8). The
agent was isoflurane (96%). incidence of laryngeal carcinoma peaks after 65
years but then decreases gradually. Men are
Table 5. Induction and Inhalation Agent also more likely to develop laryngeal
Agent N (%) carcinoma as it is associated with smoking and
Induction
Propofol 1 (0.6)
alcohol consumption (8,9). This study showed
Fentanyl 2 (1) that most patients had normal nutritional status.
Ketamine 0 (0) This result is similar to te Riele et al., 2018 who
Propofol and Fentanyl 30 (17)
Propofol and Ketamine 1 (0.6)
found that most patients with laryngeal
Propofol, Fentanyl and 70 (39.6) squamous cell carcinoma had a normal
Rocuronium nutritional status even after weight loss (10).
Propofol, Fentanyl and 67 (37.8)
Atracurium
Laryngeal carcinoma was the most
Propofol, Fentanyl, and 4 (2.2) frequent diagnosis in our study. This result is in
Lidocaine line with a previous study that described
Propofol, Fentanyl, and 1 (0.6)
Pethidine
laryngeal tumors as the most common
Propofol, Fentanyl, and 1 (0.6) laryngeal cancer (11). In our study, we
Morphine explained that micro-laryngeal surgery is a
Propofol, Fentanyl and 0 (0)
Ketamine
common procedure. Micro laryngeal surgery is
Inhalation a minimally invasive procedure often
Isoflurane 170 (96) performed in head and neck surgeries for the
Sevoflurane 7 (4)
diagnosis and therapy of pathological
conditions of the larynx (12,13). Micro
Postoperative Analgesic Use laryngeal surgery is usually safe. However, as
Metamizole injection was the most with other operations, micro laryngeal surgery
frequently used analgesic option (70.1%), has the following risks: tongue damage, tooth
followed by a combination of paracetamol and damage, lip damage, and temporary
ketorolac. hypoglossal nerve paralysis due to
laryngoscope compression. Moreover,
Table 6. Analgesia Postoperative
Analgesic N (%)
tracheostomy devices must be available in the
Paracetamol 15 (8.5) operating room during the surgery (13).
Metamizole 124 (70.1) Anesthesia induction can generally use
Ketorolac 11 (6.3)
Paracetamol dan Ketorolac 4 (2.2)
inhalation or intravenous agents. Intravenous
Paracetamol dan Metamizole 15 (8.5) agents are the most commonly used induction
Paracetamol dan Fentanyl 1 (0.6) agents. Propofol, etomidate, and ketamine are
Metamizole dan Ketorolac 3 (1.6)
Metamizole dan Tramadol 3 (1.6)
the most commonly used intravenous agents
Ketorolac dan Tramadol 1 (0.6) (14). While opioids can also be used for
induction, they are more often used for other
This study found that most patients purposes. Inhalation agents are also commonly
belonged to the age group between 45-65 years, used for induction in children (15).
and the majority were men. This result is Each anesthetic agent has its advantages
similar to Nocini et al., 2020 who found that the and disadvantages, and none is superior to the
incidence of laryngeal carcinoma increased other (16). Propofol is highly lipid-soluble, has
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a fast induction time, and short duration due to Meanwhile, the vital capacity induction
rapid redistribution (14). However, propofol is technique with sevoflurane provides the same
very painful when injected (14), causes dose- intubation and induction conditions as the
dependent respiratory depression and standard intravenous induction technique with
hypotension, and has poor analgesic properties propofol, fentanyl, and rocuronium. However,
(17). Ketamine has sedative and analgesic it provides a longer induction time (18).
properties due to its favorable hemodynamic Propofol and volatile anesthetic agents are
profile (17,18). It also protects airway reflexes an important part of modern general anesthesia
and spontaneous breathing (17). Although it is and provide many benefits in clinical anesthetic
classified as an induction agent, it does not practice and perioperative medicine (24). The
achieve anesthesia in the arm-brain circulation use of inhalation agents to maintain general
(14). anesthesia was chosen in this study. The
Etomidate, as a sedative and hypnotic researchers found different results in previous
drug, has a good hemodynamic profile but is studies. Several studies have shown that TIVA
associated with suppressing adrenocortical reduces PONV, the emergence of agitation, and
function (14,19). Opioids with high doses can blood loss while having high surgeon
also be used for sedation, but this is associated satisfaction compared to volatile anesthetic
with chest wall stiffness (20). Inhaled agents to maintain general anesthesia (25,26).
anesthetics can be used as induction agents, but However, volatile anesthetics still have the
their effectiveness is strongly influenced by advantage that tracheal extubation and
cardiac output, alveolar ventilation, inspired respiratory recovery are significantly faster
volatile agent concentrations, and gas partition (25). The use of low-flow anesthetics has many
coefficient (14). advantages in reducing atmospheric pollution,
Most common anesthetics use a cost effects, and efficient maintenance of
combination of different drugs that work airway temperature and humidity (27). Several
synergistically with one another. Recent studies have also shown that the hemodynamic
anesthetic strategies have prioritized the use of instability between the two techniques is not
these synergistic drugs to reduce the dose and much different (25,26).
dose-dependent side effects of single General anesthetic techniques are used in a
substances (21). Previous studies have also wide variety of surgeries. General anesthesia
shown that using a mixture of “Ketofol” as an has obvious advantages, such as an immovable
induction agent provides hemodynamic surgical field to perform a more precise
stability and BIS assessment between propofol surgical operation, effective respiratory tract
and ketamine (17). Likewise, the combination protection, adequate analgesia, and ventilation
of propofol and fentanyl shows a better (28). However, one of the effects of isoflurane
sedative effect, reduces the incidence of and sevoflurane, a commonly used inhalation
respiratory depression, and provides anesthetic, is bleeding. Researchers have
hemodynamic stability (22). Furthermore, differences of opinion regarding the use of
according to research conducted by Azeem et isoflurane with sevoflurane. Isoflurane
al., 2020 the combination of ketamine and provides a better surgical outlook than
propofol is better in maintaining hemodynamic sevoflurane in adenotonsillectomy surgery due
stability than fentanyl and propofol (23). to the lower amount of bleeding in isoflurane
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(29). Whereas sevoflurane has an inhibitory narcotic drugs (41). NSAIDs are safe
effect on coagulation and platelet aggregation analgesics, provide adequate pain control
(30). In addition, in previous studies, platelet during septoplasty/rhinoplasty, are
aggregation induced by ADP, epinephrine, inexpensive, and reduce postoperative rescue
arachidonic acid, prostaglandin G2, and analgesia (opioids) (42). Several guidelines
thromboxane A2 receptor agonists were recommend postoperative multimodal
suppressed by sevoflurane (31). However, analgesia and strongly recommend
isoflurane does not inhibit the platelet postoperative non-opioid analgesia unless
aggregation induced by ADP (32). Research contraindicated (43,44).
conducted by Özkiris et al., 2013 concluded Furthermore, the use of NSAIDs is not
that sevoflurane reduces the amount of indicated in coagulopathy, renal failure, or the
intraoperative bleeding in nasal septal surgery, risk of bleeding (36). Research by Nguyen et al.
this is because isoflurane can increase the (2019) described no significant bleeding events
perfusion of the nasal mucous membrane and following the perioperative administration of
surgical bleeding (28). NSAIDs and supported their use as an effective
The management of postoperative pain non-opioid alternative (42).
management in this study mostly used NSAIDs
alone. Metamizole is the most frequently used CONCLUSION
NSAID. In our study, the most common General anesthetic techniques are often
procedures were minor procedures that did not used for airway surgeries. The induction
damage a lot of tissue (i.e., 35.8% were micro- technique generally uses intravenous agents.
laryngeal surgery, followed by 15% were Each intravenous agent has its advantages and
Functional Endoscopic Sinus Surgery (FESS)). disadvantages. A combination of different
Most studies showed that postoperative pain induction agents provides synergistic benefits
after a FESS is generally mild to moderate (33– by reducing the dose-dependent side effects of
35). A study conducted by Bianchini et al. a single intravenous agent. In this study,
(2016) also showed that minor surgeries (i.e., isoflurane was the most common agent used.
tracheotomies) require sufficient NSAIDs as Isoflurane provides a better surgical field for
effective pain medication (36). airway surgery and reduces postoperative
The use of metamizole as a basic drug after complications. This advantage is obtained
tonsillectomy surgery showed lower maximal because the amount of bleeding is lower with
pain, lower use of additional opioids, and lower isoflurane. Metamizole is the most commonly
need for increased analgesic treatment (37). used analgesic agent. In addition, the use of
Likewise, in septorhinoplasty surgeries, NSAIDs can reduce opioid use and reduce the
metamizole consumption was significantly harmful effects of opioids. Most airway
decreased for three postoperative days surgeries in this study took less than 60
compared to ibuprofen (38). Unfortunately, minutes. The most common diagnosis was
metamizole is associated with agranulocytosis laryngeal carcinoma, with micro-laryngeal
(39,40). However, agranulocytosis caused by surgeries being the most common surgical
metamizole is rare (40). procedure.
The use of opioids should be reduced to
avoid the potential dangers of excessive
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Acknowledgement 9. Chen WC, Chuang HC, Lin YT, Huang

None CC, Chien CY. Clinical impact of human
papillomavirus in laryngeal squamous cell
Conflict of Interest
carcinoma: A retrospective study. PeerJ.
All authors stated there is no conflict of interest
in this study. 2017; 2017(5): 1–13.
10. Te Riele RJL., Dronkers EA., Van den
Funding Brink M., De Herdt M., Sewnaik A,
This research did not receive any funding. Hardillo J., et al. Influence of anemia and
BMI on prognosis of laryngeal squamous
Authors’ Contributors cell carcinoma: Development of an
All authors have contributed to all process in
updated prognostic model. Oral Oncol.
this research.
2018 ;78: 25–30.
11. Tambajong RN, Lalenoh DC, Kumaat L.
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