air way blocks 3/15

Question 1

what is the sensory innervation head, face and neck:

1. cranial nerve that services the face and head?
   - –a. what are the 3 branches?
   - –b. what is the 1 branch that services the nose?
   - –c. what are its 2 branches
2. cranial nerve that services mouth?
3. cranial nerve that services larynx and stomach?
   - –what are its 2 branches in the larynx?

Answer 1

Sensory Innervation

1. Trigeminal Nerve (CN V)
   - –a. opthalmic (v1),maxillary (v2), mandibular (v3)
   - –b. Maxillary V2
   - –c. anterior ethmoidal & sphenopalatine ganglion
2. Glossopharyngeal Nerve (CN IX)
3. Vagus Nerve (CN X)
   - -Superior Laryngeal nerve & Recurrent Laryngeal nerve

Question 2

what is the trigeminal distribution (3 parts)?

Answer 2

1. opthalmic (V1)
2. maxillary (V2)
3. mandibular (V3)

Question 3

what areas does the V2 branch of the trigeminal nerve serve?

Answer 3

nose, nasopharynx (upper)

Question 4

what areas does the glossopharyngeal serve?

Answer 4

the mouth, tongue, oropharynx

Question 5

1. what areas does the vagus nerve serve?

2. what are 2 of its branches?

Answer 5

1. the epiglottis down to stomach

2. recurrent and superior laryngeal nerves

Question 6

superior laryngeal nerve services:

Answer 6

• mucosa above vocal cords

- (External branch services cricothyroid muscle)

Question 7

recurrent laryngeal nerve services:

Answer 7

mucosa below vocal cords

(Also controls 4 of the 5 intrinsic larynx muscles: posterior, lateral & thyroarytenoid, and arytenoides muscles.

Question 8

1. Nerve V2 is a branch of the ___ nerve?
2. nerve V2 is called the ___ nerve? what does it innervate?
3. what nerves does it branch into?

Answer 8

1. V2 is a branch of the TRIGEMINAL NERVE
2. called the MAXILLARY NERVE; supplies innervation to nose
3. branches into the:
   - –ANTERIOR ETHMOIDAL
   - –SPHENO-PALATINE GANGLION

Question 9

sphenopalantine nerves

1. how many branches
2. what do they service
3. what is it a branch of?

Answer 9

1. 2 branches (long and short)
2. – Long: inside of nose and soft palate;
   - -Short: sphenoid tissue
3. sphenopalating ganglion via maxillary nerve branch (V2) of the trigeminal nerve (CN V)

Question 10

glossopharyngeal nerve-what branch services everything?

Answer 10

lingual branch of glossopharyngeal services posterior section 1/3 the tongue (dont confuse it with lingual nerve (from v3))
-also services vallecula of oropharynx

Question 11

vagus nerve
superior laryngeal nerve
1. what does it innervate
2. how many branches
3. what do branches do and service

Answer 11

1. area above vocal cords;
2. 2 branches
   3a. internal branch which dives thru thyrohyoid membrane and innvervates the mucosa
   3b. external branch- descends on top of the larynx under the sternothyroid muscle and provides motor to crycothyroid muscle

Question 12

vagus nerve
recurrent laryngeal nerve:
1. where does each loop run under?
2. where does it enter and what does it control?

Answer 12

1. loops under subclavian (inominate artery) on right and aorta on left
2. enters below thyroid cartilage and gives motor innervation to rest of vocal cord muscles (arytenoides, posterior areytenoid, lateral areytenoid & and thyroaretynoid)

Question 13

what is the gold standard for airway management (preemptorally)

Answer 13

fiberoptic bronchoscope

Question 14

when the SLN nerve is blocked, sensory innervation to what is blocked?

Answer 14

Provides Sensory block to:
-base of tongue
‐ posterior surface of epiglottis
‐ aryepiglottic folds
‐ arytenoids
(i.e. mucosa above vocal cords).

Question 15

SLN block:

what is the needle size, drug (&%), and dose?

Answer 15

-Needle / Drug / Dose
 5/8 ” 25‐g needle
 2% lidocaine
 2 – 3 mL bilaterally

Question 16

glossopharyngeal nerve block provides sensory block to ?

Answer 16

GPN Block provides
Sensory block to:
- posterior 1/3 of tongue
‐ vallecula
‐ anterior surface of epiglottis
‐ walls of the pharynx
‐ tonsils

Question 17

1. what block is an abrams needle used for?
2. what is special about this needle?
3. why is this needle infrequently used?
4. refersher course: what is the order of pillars, tonsils, nerves and arteries in the mouth?

Answer 17

1. Glossopharyngeal block (more proximal)
2. it is a bent needle to get around the pillar of fauces
3. because the block is very hard to do, the nerve sits behind palatopharyngeal pillar of fauces (it is near (behind) the internal carotid artery).
4. palatoglossal pillar>palatine tonsil> palatopharyngeal pillar>internal carotid artery<glossopharyngeal nerve

Question 18

if you are using spray to anesthetize the airway (instead of airway blocks), what should you expect?

Answer 18

patient will probably still gag with spray

Question 19

how to block the lingual branch of GPN:

Answer 19

1. 5 cc syringe on a 3.5 inch 25 g spinal needle

2. inject 2 cc in the band of tissue on the side of the tongue

Question 20

Clinical Caveats (GPN Block):

1. GPN can be blocked intra‐orally in 2‐different areas by injection, what are they?
2. what other ways can it be anesthetized (a,b)?

Answer 20

1. behind the palatoglossal pillar or along the side of the tongue
2.  Other options are direct topical application of sprays
    Tongue blade with gauze soaked in lidocaine cream at base of tongue

Question 21

Clinical Caveats to (RLN Block) recurrent laryngeal block:

1. what does it do?
2. where is the injection level?
3. what is an alternative?
4. what is a good needle type to use?

Answer 21

1. RLN provides sensory to vocal cords & trachea
2. Injection at the level of the cricothyroid membrane works well as long as the clinician is mindful of patient selection/comfort
3. RLN can also be blocked by instillation via the FOB
4. use an angiocath so that when the patient coughs, they wont get scraped up.

Question 22

anesthetizing the mouth and nose via Nebulizers:

1. what is the amount and dose of the anesthetic? what is the o2 flow?
2. what factors affect efficacy of the nebulized block?
3. what is the the flow that gives the optimal droplet size? what is the droplet size?
4. what are caveats to nebulized anesthetic?

Answer 22

1. a) 5 ‐ mL of 4% lidocaine; b)O2 6 – 8 L/min
2. size of droplet, flow and nebulizer type
3. Flow < 6 L/min O2 = 30 – 60 micrometer droplet size (smaller is better)
4. takes time & cooperative patient necessary

Question 23

what are the 2 types of specialty atomizers (that go down throat)?

Answer 23

-2 types of Atomizers

DeVilbiss Atomizers & ’MAD’ Atomizers

Question 24

MAD (or MADgic)

Answer 24

• -It is a long angled straw like attachment that attaches to a 3 cc syringe
• -draw up 4% into the syringe
• -depress into larynx

Question 25

where does superior laryngeal nerve end?

Answer 25

bilat piriform fossa

Question 26

DeVilbiss atomizer

Answer 26

looks like a perfume atomizer: has a bulb on the end or a bleed hole on the end of the air supply tubing.
you either depress the bulb or cover the bleed hole and anesthetic is sprayed into the back of the larynx.

Question 27

why place 4 swabs into each nare (per Dr. Ovasappian)

1. swab #1
2. swab #2
3. swab #3
4. swab #4

Answer 27

swabs: 1-4
1. anterior ethmoid branch (upper nose)
2. spheno-palatine ganglion (long and short branches of sphenopalatine)
3. ??numb posterior nasopharynx
4. runs along the floor of the nose; tells you that you can pass a 7.5 cm tube thru the nose

Question 28

how to intubate thru a LMA

Answer 28

1. cook aintree,
2. intubator fits over the 4mm bronchoscope
3. place aintree and bronchoscope thru slats in LMA
4. pull LMA and thread ET tube over aintree, inflate and secure

Question 29

which branch of the superior laryngeal nerve is blocked in a SLN block?

Answer 29

the internal branch which runs into the thyro-hyoid membrane