ENT surgery and the shared airway

Patient and surgery

In ear, nose and throat surgery the surgeon works in the airway the anaesthetist must keep open, so both plan together for blood, fire and difficult tubes.

Updated Nov 13, 2026

Key points

The fire triangle is an oxidiser (oxygen, nitrous oxide), an ignition source (laser, electrosurgery) and a fuel (tube, drapes, gauze): remove one to prevent fire.
During laser airway surgery use the lowest oxygen concentration that keeps saturation safe, avoid nitrous oxide, use a laser-resistant tube and fill its cuff with saline.
Airway fire: stop the laser, remove the tube, stop gas flow, pour saline into the airway, then ventilate with air and re-intubate and inspect with a bronchoscope.
Post-tonsillectomy bleeding is a full stomach in a hypovolaemic patient: resuscitate first, then rapid-sequence induction with two suctions and an experienced operator.
For a predicted difficult airway, agree the plan and backups with the surgeon beforehand; awake intubation or tracheostomy under local may be the safest first plan.

What it is

In ear, nose and throat surgery the anaesthetist and the surgeon share the airway: the surgeon operates in or beside it while the anaesthetist must keep it open, protected and ventilated, often from the far end of a turned table with the head under drapes. Many patients have a predicted difficult airway because of tumours, abscesses, trismus, previous radiotherapy, stridor or obstructive sleep apnoea, so the plan starts with careful airway assessment, a clear primary plan and backups agreed with the surgeon, including awake tracheal intubation or a tracheostomy under local anaesthesia when needed. Special tubes are chosen to keep out of the surgical field: reinforced or preformed tubes, small microlaryngeal tubes, or laser-resistant tubes; some cases use no tube at all, with jet ventilation, high-flow nasal oxygen or spontaneous breathing. Blood and debris in the pharynx threaten the airway, so throat packs are used and must be removed and counted. Laser and electrosurgery near oxygen create the risk of airway fire, the classic catastrophe of this specialty. Emergence must be smooth, because coughing causes bleeding and laryngospasm is common after airway surgery. Bleeding after tonsillectomy is a separate emergency: a hypovolaemic patient, often a child, with a stomach full of blood and a bloody view.

What changes in this patient

Shared field: the surgeon works in the airway, the head is far from the anaesthetist, and tube position can change with surgical moves.
Difficult airway: tumours, abscesses, trismus, stridor, previous radiotherapy or surgery, and obstructive sleep apnoea are common.
Tubes: reinforced, preformed, microlaryngeal or laser-resistant tubes, or tubeless techniques with jet ventilation or high-flow nasal oxygen.
Blood: secretions and blood soil the airway; throat packs protect it but can be forgotten and cause obstruction after extubation.
Fire: lasers and electrosurgery near an oxygen-rich airway can ignite the tube, drapes or gauze.
Ear surgery: nitrous oxide expands the middle ear and can lift a graft; facial nerve monitoring means avoiding prolonged neuromuscular block; nausea is common.

Anaesthetic plan (and why)

Assess the airway in detail, including nasendoscopy or imaging findings shared by the surgeon — the lesion may be invisible from the mouth.
Agree a primary plan and backups with the surgeon before induction, including who performs front-of-neck access — shared plans prevent hesitation.
Choose awake tracheal intubation or tracheostomy under local anaesthesia when mask ventilation or intubation may fail — the patient keeps breathing.
Secure and check the tube after every change of position, and use reinforced or preformed tubes — kinking and dislodgement are hidden under drapes.
Insert a throat pack when blood is expected, record it and remove it before extubation — a forgotten pack causes airway obstruction.
For laser or electrosurgery near the airway, lower the oxygen, avoid nitrous oxide and wet the swabs — removes oxidiser and fuel from the fire triangle.
Consider controlled lower blood pressure and head-up tilt for sinus surgery — a drier field improves the view and shortens surgery.
Suction the pharynx under direct vision and extubate smoothly, awake or with a planned deep technique — coughing causes bleeding and laryngospasm.
Treat a post-tonsillectomy bleed with fluid or blood first, then rapid-sequence induction with two suctions — the stomach is full and the view bloody.

Main anaesthetic concerns by type of ENT surgery

Surgery	Main concern	Usual answer
Tonsillectomy	Shared airway, sleep apnoea, bleeding	Reinforced or preformed tube, throat pack, careful opioids, antiemetics
Laser laryngeal surgery	Airway fire, small airway	Laser-resistant tube or tubeless technique, low oxygen, no nitrous oxide
Sinus surgery	Bleeding obscures the view	Head-up tilt, controlled blood pressure, smooth emergence
Middle ear surgery	Graft lift, facial nerve monitoring, nausea	Avoid nitrous oxide, limit neuromuscular block, antiemetic prophylaxis
Head and neck tumours, abscesses	Difficult or obstructed airway	Awake intubation or tracheostomy under local, front-of-neck access ready

Risks and complications

Failed intubation or a cannot-intubate, cannot-oxygenate situation in a patient with a distorted airway.
Airway fire with burns of the airway and lungs.
Tube kinking, dislodgement or disconnection under drapes; barotrauma and pneumothorax during jet ventilation.
Aspiration of blood, a retained throat pack, and laryngospasm or bronchospasm at emergence.
Post-tonsillectomy bleeding with hypovolaemia and aspiration; postoperative airway obstruction in children with obstructive sleep apnoea.
Severe nausea and vomiting after middle ear and tonsil surgery.

Next step

In recovery, watch for bleeding, stridor and obstruction, especially after tonsillectomy and in children with sleep apnoea, and confirm the throat pack was removed.
Call a senior at once for stridor, a fresh bleed or falling saturation; prepare for re-intubation with the surgeon present.
After any airway fire, admit to intensive care, inspect the airway with a bronchoscope and report the event.
Give multimodal analgesia with limited opioids and antiemetic prophylaxis, since pain and vomiting worsen bleeding.
Record in the notes how the airway was managed and any difficulty, and give the patient a written airway alert when relevant.

Test yourself

Think of the answer, then tap the question to see it.

What are the three sides of the fire triangle in airway surgery?

An oxidiser (oxygen or nitrous oxide), an ignition source (laser or electrosurgery) and a fuel (the tube, drapes, gauze or alcohol prep). Removing any one prevents fire.

What are the first actions in an airway fire?

Stop the laser, remove the tube, stop the gas flow and pour saline into the airway; then ventilate with air, re-intubate and inspect the airway with a bronchoscope.

Why is a bleeding tonsil after tonsillectomy an anaesthetic emergency?

The patient may be hypovolaemic, has swallowed blood (a full stomach) and the view is bloody; resuscitation comes first, then rapid-sequence induction by an experienced operator.

Why is nitrous oxide avoided in middle ear surgery?

It diffuses into the closed middle ear faster than nitrogen leaves, raising pressure that can lift the tympanic graft; on stopping it, negative pressure follows.

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Educational content; it does not replace supervised training, your institution's protocols or the anaesthetist's or intensivist's decision. It contains no doses and no ventilator or infusion settings.

Sources: Surgical Fire Safety (StatPearls (NCBI Bookshelf), 2023); Difficult Airway (StatPearls (NCBI Bookshelf), 2026).

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