Nasal Surgery With or Without General Anesthesia

Nasal septoplasty is one of the most commonly performed procedures within otorhinolaryngology (ENT). The primary indication for this surgery is usually septal deviation resulting in significant and symptomatic nasal airway obstruction. Septoplasty can be performed alongside or in addition to rhinoplasty, turbinoplasty, or as part of functional endoscopic sinus surgery to improve surgical exposure and access. Operative recovery usually lasts a few weeks, and serious complications are rare (1). Historically, septoplasties were commonly performed under general anesthesia (GA). In recent years, the use of local anesthesia with conscious sedation (SDA) has increased. General anesthesia is advantageous in septoplasty, and other forms of nasal surgery, owing to the provision of full analgesia, safe airway, and no requirement for patient cooperation. On the other hand, SDA has the advantage of not requiring intubation or mechanical ventilation, together with fewer cases of postoperative nausea and/or vomiting. However, there is no consensus as to the procedure of choice (2). While some patients may have conditions contraindicating one or the other, for others, the decision of whether to perform the nasal surgery with or without general anesthesia will depend on patient, surgeon, and anesthesia provider preference.

In a 2014 study published in the European Archives of Otorhinolaryngology, Daşkaya et. al conducted a study to assess whether general anesthesia or SDA is more efficacious in nasal septal surgery. A prospective chart review of 60 patients, between the ages of 16 and 65, who underwent septal surgery under GA or SDA during a 1-year period was done (3). Patients were classified into two groups: group 1 consisted of 30 patients who had GA and group 2 consisted of 30 patients who had SDA. The medications used in general anesthesia were IV 1 μg/kg fentanyl, 2 mg/kg propofol, and 0.5 mg/kg rocuronium, 2 minutes after IV 2 mg midazolam application. GA utilized oro-tracheal intubation (3). SDA was performed with IV 0.04 mg/kg midazolam, 1.5 mg/kg propofol, and 1 μg/kg fentanyl, 5 min before the surgery. According to the Ramsey sedation scale, 0.3 mg/kg propofol and 25 μg fentanyl were also injected to the patients during the surgery (3). 36 male patients (60%) and 24 female patients (40%) with a mean age of 44.30 ± 13.29 were included in the study. There was no significant difference between groups for gender and age (p = 0.60, p = 0.23).

It was found that postoperative vomiting was significantly higher in group 1 (3.66 ± 1.09 vs 2.06 ± 1.22, p<0.01), which was consistent with prior studies (3). Additionally, total operation time was longer in group 1 than group 2 (56.10 ± 9.42 mins vs 35.13 ± 8.34 mins, p<0.01). The prolonged operation time in group 1 was most likely related to the higher intraoperative bleeding volume in group 1 (31.96 ± 23.13 cc) compared to group 2 (19.83 ± 21.34 cc) (p=0.03). Furthermore, when hospital cost was evaluated excluding surgery charge, calculated cost per patient in group 1 was $44.35 ± 10.81 and $16.29 ± 11.88 in group 2 (p < 0.01). This may be related to much longer hospital stay in group 1 than group 2 (31.43 ± 13.25 hrs vs 15.36 ± 9.49 hrs, p < 0.01). Based on these findings, it can be seen that septoplasty under SDA is typically more cost-effective and more comfortable than GA. However, general anesthesia should still be used for revisions and more complex nasal surgery, such as total septal reconstruction and septorhinoplasty (3).

References

1. Watters C, Brar S, Yapa S. Septoplasty. In: StatPearls. Treasure Island (FL): StatPearls Publishing; November 8, 2022.

2. Dogan R, Erbek S, Gonencer HH, Erbek HS, Isbilen C, Arslan G. Comparison of local anaesthesia with dexmedetomidine sedation and general anaesthesia during septoplasty. Eur J Anaesthesiol. 2010;27(11):960-964. doi:10.1097/EJA.0b013e32833a45c4

3. Daşkaya H, Yazıcı H, Doğan S, Can IH. Septoplasty: under general or sedation anesthesia. Which is more efficacious?. Eur Arch Otorhinolaryngol. 2014;271(9):2433-2436. doi:10.1007/s00405-013-2865-6