HEENT

Last updated: February 9, 2026

Cochlear Device Implantation

Access: PIV x1
Airway: Oral ETT
Induction: Standard (Lidocaine/Propofol/Fentanyl (or remifentanil bolus)
Maintenance: TIVA (propofol/remifentanil/phenylephrine).
Emergence: Awake
Antibiotics: Cefazolin
Position: 180 Supine
Special: Facial nerve monitoring

Direct Laryngoscopy with Biopsy

Access: PIV x1
Airway: Usually Oral ETT 6-0
Induction: Standard
Maintenance: Can run TIVA (propofol/remifentanil/phenylephrine) or gas/paralytic
Emergence: Awake
Antibiotics: None
Position: 90 Right
Special: ENT Surgeons usually have specific preferences. Email is usually sent out → ask for it if needed.
ETT → usually 6-0.
Consider remifentanil bolus (but probably 1 mcg/kg over 1 min), 2 over 2 tends to be too much → slow wakeup, these cases are usually fast

Drug-Induced Sleep Endoscopy

Access: PIV x1.

Airway: Nasal cannula with inline CO2 on mouth, 2-4 L. No intubation.

Induction: Check with attending on whether glycopyrrolate 0.2-0.4 on entry to OR, but per request of surgeons.

Maintenance:

Lidocaine 20-40 mg IV push.

Propofol MAC with BIS 50-70 connect directly to IV. Avoid any other sedatives (Midazolam, fentanyl)

If the web program is unavailable

Program 1000 mcg/kg over 4 min (record on Epic as 250 mcg/kg/min). Infusion: 500 mcg/kg/min until target (airway collapse), then pause and wait 90 seconds. Maintenance: 150-200 mcg/kg/min titrated to clinical signs of degree of obstruction.
Emergence: Awake
Antibiotics: None

Position: 180 Supine with circle pillow, then sometimes patient’s right side.
Special: Protocol in Appendix

GI Endoscopy MAC Macro in PennChart. Attending to log into WebDISE (aws.jeffmandel.org).

Obtain donut pillow.

Glossectomy

Access: PIV x2

Airway: Nasal or Oral ETT. Since intra-oral procedure, may need either nasal intubation or if orally intubated, tape tube opposite surgical site and consider down-sizing one size. Also, ensure ETT is in appropriate piriform sinus.

Induction: Standard

Maintenance: Can run gas/paralytic or TIVA (propofol/remifentanil/phenylephrine)
Emergence: Awake
Antibiotics: Cefazolin or Ampicillin/Sulbactam

Position: 180
Special: Nasal or Oral ETT.

Nasal Endoscopy for epistaxis

Access: PIV x1-2

Airway: Oral ETT. (avoid taping philtrum)

Induction: Standard (Lidocaine/Propofol +/- Rocuronium)

Maintenance: Can run gas/paralytic or TIVA (propofol/remifentanil/phenylephrine) (short case, so no remifentanil bolus or 1 mcg/kg/min over 1 min)
Emergence: Awake
Antibiotics: Cefazolin

Position: 180
Special: None

Nasal Endoscopy for ethmoidectomy

Access: PIV x1-2

Airway: Oral ETT. (avoid taping philtrum)

Induction: Standard (Lidocaine/Propofol +/- Rocuronium)

Maintenance: Can run gas/paralytic or TIVA (propofol/remifentanil/phenylephrine) (short case, so no remifentanil bolus or 1 mcg/kg/min over 1 min)
Emergence: Awake
Antibiotics: Cefazolin

Position: 90 or 180
Special: None

Micro Direct Laryngoscopy with Vocal Cord Injection (Mirza)

Access: PIV x1
Airway: Either Jet ventilation or HFNC, sans airway securement (but have backup equipment ready. LMA, MLT 5-0, MLT 6-0, VL-D)
Induction: Standard (Lidocaine/Fentanyl/Propofol) +/- Rocuronium
Maintenance: TIVA (propofol/remifentanil/phenylephrine). consider remifentanil bolus 2 mcg/kg over 2 min or 1 mcg/kg over 1 min
Emergence: Awake
Antibiotics: None
Position: 90
Special: Relatively quick injections, 5-10 minute each.
Consider dexamethasone, ondansetron, ketorolac. Usually do not need intra-op opiate (fentanyl, hydromorphone)
Atkins likes 200 mg celecoxib PO post-op.

Micro Direct Laryngoscopy with Excision Tumor +/- stripping +/- Laser (Mirza)

Access: PIV x1
Airway: 5-0 Oral ETT Laser. In PCAM, in a bottom shelf near a door. Have a circuit extension. Place Christmas tree near patient hip.
Induction: Standard (Lidocaine/Fentanyl/Propofol) +/- Rocuronium
Maintenance: TIVA (propofol/remifentanil/phenylephrine). remifentanil 1 mcg/kg over 1 min bolus (fairly short cases, depends on how much paralytic is use)
Emergence: Awake
Antibiotics: None
Position: 90
Special: Consider ketorolac for pain, pre-op acetaminophen. Usually do not need intra-op opiate (fentanyl, hydromorphone)
Consider dexamethasone (surgeon may request for or against)

Parotid Tumor Excision

Access: PIV x2
Airway: Oral ETT
Induction: Standard (Lidocaine/Fentanyl/Propofol)
Maintenance: TIVA (propofol/remifentanil/phenylephrine). Neuromonitoring for Facial Nerve.
Emergence: Awake
Antibiotics: None
Position: 180
Special: Due to facial nerve monitoring, the eye may be exposed. Utilize carboxymethylcellulose eye drops + tegaderms for protecting eyes. Also, ensure ETT is in appropriate piriform sinus.

Stapedectomy

Access: PIV x1-2
Airway: Oral ETT
Induction: Standard
Maintenance: TIVA (propofol/phenylephrine) + Paralytic. Could also do remifentanil, could also do gas. But middle ear surgery → consider PONV
Emergence: Awake
Antibiotics: Cefazolin.
Position: 180
Special: Laser eye protection? Consider FiO2 < 30 if lasering, no nitrous given middle ear space.

Temporomandibular Joint Arthroplasty

Access: PIV x2

Airway: Nasal RAE 6-0 females, 7-0 males. Usually do not need reinforced. Either nares is fine, ETT will go up over forehead. Have circuit extension.

Induction: Standard (Lidocaine/Fentanyl/Propofol) +/- Rocuronium

Maintenance: TIVA (Propofol/remifentanil/phenylephrine). Or gas
Emergence: Awake
Antibiotics: Cefazolin

Position: 0. Bed down, head up.
Special: Get BIS on in time prior to headwrap by surgeon

Tracheostomy (Awake)

Access: PIV x1

Airway: This is an awake trach. Surgeon-led with local anesthetic injections.

Induction: Reassurance and calm coaching.

Maintenance: This is an awake trach, not a sedated trach.
Consider midazolam or fentanyl given their reversal agents (flumazenil and naloxone). Dexmedetomidine may also be considered (no reversal agent). Administer medications cautiously.

Have propofol and paralytic ready once trach is secure to send patient off to sleep
Emergence: Awake
Antibiotics: Cefazolin.

Position: 0. Supine
Special: None.

Tracheostomy (already intubated)

Access: PIV x1

Airway: Patient already has airway secured with ETT.

Induction: Hook up ETT to machine, ventilate, turn on gas.

Maintenance: Gas and paralytic
Emergence: Awake
Antibiotics: Cefazolin.

Position: 0. Supine
Special: Depending on surgeon and technique, it may be necessary to go down on FiO2 < 30% to reduce fire risk once they are close to trach and bovie’ing.

If they are using a percutaneous technique, FiO2 reduction may not be required, but a fiberoptic scope should be ready to visualize the wire from above.

In any case, have backup airway equipment ready, do not lose the secured ETT, communicate with the surgeon on FiO2 to avoid fire.