Anesthesia for Ear, Nose, and Throat (ENT) Flashcards
1
Q
What provides motor innervation to intrinsic muscles of the larynx
A
Right and Left Recurrent Laryngeal Nerves (RLN)
2
Q
The Recurrent Laryngeal Nerves do NOT provide innervation to these larynx structures.
A
- Cricothyroid
- Inferior pharyngeal constrictor muscles
3
Q
The Recurrent Laryngeal Nerves will provide sensory innervation to what structures?
A
- Sensory below the vocal cords
- Sensory of the upper trachea
4
Q
Internal laryngeal nerve (branch of superior laryngeal nerve) will provide sensory to what structure?
A
Sensory above vocal cords
5
Q
Presentation of unilateral injury to the RLN.
A
- Hoarseness from unilateral loss of vocal cord abduction occurring in conjunction with intact cricothyroid-mediated adduction
- Affected vocal cord will rest in a paramedian position
6
Q
Presentation of bilateral injury to the RLN.
A
- Dyspnea
- Stridor
- Full airway obstruction from a bilateral vocal cord in paramedian positioning.
7
Q
What intervention will be indicated in a patient with bilateral RLN damage?
A
Tracheostomy
8
Q
What are the two branches of the Superior Laryngeal Nerve?
A
- External Branch
- Internal Branch
9
Q
What is the external branch of the SLN responsible for?
A
Motor to cricothyroid muscle & inferior pharyngeal muscles
10
Q
What is the internal branch of the SLN responsible for?
A
Sensory to laryngeal mucosa above vocal cords
11
Q
What are examples of external ear surgery?
A
- Foreign body removal
- Removal of tumors
- Cancers
12
Q
What are examples of middle ear surgery?
A
- Myringotomy
- Tympanoplasty
- Stapedectomy
- Mastoidectomy
Most of the middle ear surgery with the exception of myringotomy will be done under general anesthesia
13
Q
What needs to be avoided for middle ear procedures?
A
Nitrous Oxide
14
Q
What ear procedure is most commonly performed in children
A
Myringotomy with tube placement.
15
Q
Anesthesia for Myringotomy
A
Sevoflurane mask anesthesia
16
Q
What procedure is done to treat otosclerosis?
A
Stapedectomy
GETA
17
Q
What are examples of inner ear surgery?
A
- Cochlear implant
- Surgery to Endolymphatic sac or Labyrinth
18
Q
Most patients involved in ear procedures are prone to _________.
A
PONV
19
Q
Why do you want controlled hypotension with a mastoidectomy?
A
To control bleeding
20
Q
Anesthesia considerations for ear surgery
A
- Most of the time GETA
- Reinforced or RAE tube
- No N2O in middle ear surgery (risk of barotrauma)
21
Q
Fick’s Law of Diffusion
A
Rate of diffusion of a substance across a membrane is related to concentration gradient, surface area, solubility, membrane thickness, molecular weight
- N2O is more soluble than nitrogen
- N2O diffuses into air containing cavities more rapidly than nitrogen (risk of barotrauma)
22
Q
Anesthesia Consideration for Stapedectomy
A
- Laser precautions
- Facial nerve monitoring
- Deliberate hypotension
- PONV (use at least 3 antiemetics)
- Gentle emergence (Deep extubation?)
23
Q
Identify which medications should be avoided in the anesthesia plan for a patient presenting for a tympanoplasty & mastoidectomy.
A
- Nitrous Oxide
- Non-depolarizing muscle blockers depending on facial nerve monitoring
24
Q
What preop assessments are focused on nasal procedures?
A
- OSA
- HTN
- Samter Triad
Samter Triad = Nasal polyps , Asthma, Sensitivity to ASA/NSAIDS
25
What is the Samter Triad. What is the significance?
* Nasal polyps
* Asthma
* Sensitivity to ASA/NSAIDS
## Footnote
**The combination of these three factors may produce DEADLY bronchospasms**
26
How long should ASA and NSAIDs be held before nasal surgery?
1 – 2 weeks preop
27
What is the purpose of a throat pack for nasal surgery?
Prevents blood & surgical debris in pharynx & larynx
## Footnote
Document throat pack time in & out
28
What are the three vasoconstrictors used in nasal surgery?
* Cocaine 4%
* Phenylephrine
* Oxymetazoline (Afrin)
29
What is the MOA of Cocaine 4%?
What is the dose?
* Blocks reuptake of norepinephrine at sympathetic nerve terminals
* Do not exceed 1.5 mg/kg
30
Contraindication of Cocaine 4%
* CAD
* HTN
* Pt on MAOIs
31
Dose of Phenylephrine used for nasal procedures
* Solo or w/lidocaine
* Initial dose < 500 mcg
## Footnote
Treat HTN with direct vasodilators or α-receptor antagonists
32
What drugs should be avoided if phenylephrine is used for nasal surgery?
β-adrenergic blocker and CCB should be avoided because they may worsen CO and produce pulmonary edema
33
MOA of Oxymetazoline.
Dose.
* Selective α1-agonist and partial α2-agonist imidazoline-derivative
* 0.05% solution x 3 sprays
34
Contraindication of Oxymetazoline
Patients taking monoamine oxidase inhibitors
35
Emergence Consideration for Nasal Surgery
* Gastric suctioning before emergence
* Prevent coughing / bucking (↑ bleeding)
* Avoid pressure on face (lift that jaw up to the mask)
36
What are examples of Endoscopic Sinus Surgeries?
* Nasal polyposis
* Sinusitis
* Epistaxis control
* Tumor excision
* Foreign body removal
37
Anesthesia Considerations for Endoscopic Sinus Surgery
* Controlled hypotension (blood free field)
* TIVA (Propofol / remifentanil)
* Smooth wake-up
* SGA vs ETT (oral rae)
* Nasal Vasoconstriction meds
38
How will the patient be positioned if undergoing an image-guided endoscopic sinus surgery?
A special headset on the patient requires the bed to be turned 180 degrees away from the anesthesia provider.
39
Potential Complications for Endoscopic Sinus Surgery
* Orbital hematoma
* Blindness from orbital trauma
* Optic nerve injury
* CSF leak
* Carotid or ethmoid artery invasion
* Cranial cavity entry
* Hemorrhage
40
When will a patient have a Tonsillectomy performed?
* Tonsillar hyperplasia
* Recurrent tonsillitis
* Malignancy
41
When will a patient have an Adenoidectomy performed?
Hyperplasia causing nasopharyngeal obstruction
42
Lymphoid tissue posterior to the nasal cavity in the roof of the nasopharynx
Adenoids
43
When pre-oping for a Tonsillectomy/Adenoidectomy, if the patient has OSA. What other associated issues would the anesthesia provider investigate?
* Cor pulmonale
* Pulmonary HTN
* RV hypertrophy
* Cardiomegaly
44
Tonsillectomy/Adenoidectomy Anesthesia Considerations
* Oral RAE ETT or wire-reinforced ETT
* Stimulating procedure
* Consider remifentanil
* PONV
* Gastric suctioning before emergence
* Post-op PAIN!!!!
* Tonsillar local anesthetic injection
* Morphine/hydromorphone
* Avoid NSAIDs (risk of bleeding)
45
Tonsillectomy/Adenoidectomy complications
* Post-op hemorrhage
* Usually occurs within 6 hours
* May occur days later
46
Patients with nasal polyps, asthma, and sensitivity to aspirin or at risk for ________ during their procedure.
Bronchospasm
47
OSA Surgery Anesthesia Considerations
* Possible difficult ventilation & intubation
* Oral RAE tube – taped midline
* Redundant tissue, macroglossia
* Minimize opioids
* Postop hypoxia
* Dexamethasone to reduce airway edema (10 mg)
48
Patients with OSA have an increase in postoperative obstructive episodes, peaking on postoperative day ____ and returning to preoperative levels after a week
Day 3
49
A panendoscopy is a combination of what three procedures?
* Laryngoscopy
* Bronchoscopy
* Esophagoscopy
50
Anesthesia Considerations for Panendoscopy
* Anterior commissure laryngoscope is very stimulating
* Consider potent/short-acting opioid (REMIFENTANIL)
* Microlaser/ laser ETT
* Transtracheal jet ventilation (TIVA)
* Tracheostomy may be warranted
* Throat pack
* Head extended, neck flexed
* Need shoulder roll and donut
* GETA w/ muscle relaxant
* Avoid N2O and keep FiO2 low
51
What are the pros of using Microlaser/ Laser Tubes?
* All metal ETT
* Airway protection
* Ventilation control
* EtCO2 measurement
* Double cuff
52
What are the cons of using Microlaser/ Laser Tubes?
* Higher than usual ventilation pressures (narrow diameter)
* Challenging surgical access
* Tube ignition is possible when the laser is in use
53
Decribe how an anesthesia provider performs supraglottic jet ventilation.
* High-pressure O2 “breaths” @ 20 – 50 PSI
* 1 second on / 3 seconds off
54
Type of sedation required for jet ventilation
TIVA
55
Disadvantages of Jet Ventilation
* Barotrauma possible (PSI >50)
* No measurement of Vt or EtCO2
* Suboptimal for obese pts
56
Signs and symptoms of thyrotoxicosis
* Sinus tachycardia / A-fib
* MI / CHF
* Nervousness/tremulousness
* Insomnia
* Heat intolerance
* Weight loss
57
Anesthesia considers if a patient has a goiter.
* Deviation of larynx
* Tracheal compression causing airway stenosis
* Airway collapse after induction of anesthesia & muscle relaxant administration
* Horner syndrome
* SVC obstruction
58
How is hypercalcemia secondary to hyperparathyroidism treated in pre-op?
* Fluids
* Furosemide
* Bisphosphonates
59
Parathyroidectomy Lab considerations
* Baseline Ca++ & PTH
* Redraw Ca++ & PTH 10 minutes after excision of parathyroid
* Consider an arterial line
60
Thyroidectomy & Parathyroidectomy Anesthesia Considerations
* Intubation using NIM ETT, allows for identification of recurrent laryngeal & vagus nerves
* Avoid long-acting muscle relaxants
* Shoulder roll
* Avoid coughing/bucking
* Consider deep extubation
61
Between what tracheal rings will a tracheostomy be performed?
B/w 2nd and 3rd tracheal ring
62
Tracheostomy Anesthesia Considerations
* If Cautery is used → low FiO2 (under 30% O2)
* If using scalpel → higher FiO2 acceptable
* Risk of false passage creation with Shiley trach
* Have 6.0 mm ID reinforced ETT available
* Shoulder roll
63
When will a neck dissection & laryngectomy be performed?
Prevention/treatment of head & neck CA
64
Anesthesia considerations for neck dissection & laryngectomy
* 2 large bore IVs
* Arterial line
* Nerve integrity monitoring (NIM) during neck dissection
* Minimize fluid administration
* Free flap (avoid neo and levo) → graft ischemia
65
What are Le Fort Fractures?
How many types are there?
* Midfacial fractures
* 3 major types (I, II, and III)
66
Describe a Le Fort I fracture
* Horizontal fx involving inferior nasal aperture
* Separates teeth and lower maxillary components from upper facial structures
67
Describe a Le Fort II fracture
Triangular fracture with the fracture line across the nose,
below the infraorbital rim and through the entire lower maxilla
68
Describe a Le Fort III fracture
* Fx that parallels the base of the skull
* Fx of nasal, orbital, zygoma
* Mobile maxilla (occlude airway)
* Fx cribriform plate may separate nasopharynx and base
* Not common
* Needs fiberoptic intubation
69
Anesthesia Considerations for Le Fort fractures
* Rule out head /neck injury
* Neuro injury?
* C-spine precautions?
* Possible chest trauma
* Full stomach
* Bloody airway obstructing view
* Limited ROM (in line stabilization)
70
When will a patient have a Le Fort Osteotomy?
* Correct maxillary deformities
* Corrects malocclusion of teeth by movement of maxilla and/or mandible
71
Anesthesia Considerations for Le Fort Osteotomy?
* Young patients (< 30 yo)
* Nasal intubation
* Deliberate hypotension
* Minimal fluid resuscitation
* Opioids / multimodal PONV prophylaxis
* **Awake extubation**
* Jaws wired or tightly banded
72
Interventions for Allergic Reaction Angioedema
* Antihistamines
* Steroids
* H2 antagonist
* Epinephrine
* Intubation (use a smaller tube)
73
At what age is acute epiglottis most common?
2 to 6 years old
74
Cause of acute epiglottis
H-influenza
75
Signs and Symptoms of Acute Epiglottis
* Sore throat
* Dysphagia
* Drooling
* Fever
* Muffled voice
* Open-mouth tripod position
* Stridor / respiratory distress
* Total airway obstruction
76
Pediatric Management of Acute Epiglottis
* Prevent crying
* **Calm** inhalation anesthesia induction
* Maintain spontaneous respiration
* Consider smaller ETT
* Rigid bronchoscopy
* Surgical airway may be necessary
77
Adult Management of Acute Epiglottis
* Assessment of disease
* Oropharyngeal exam
* Fiberoptic nasopharyngoscopy
* ICU admission
* Inhaled mist medication/ steroids/ abx
* Awake fiberoptic intubation (safetest option)
78
What is Ludwig Angina
* Floor of mouth infection
* Starts with mandibular molars
* Spreads to submandibular, sublingual, submental, and buccal spaces
* Tongue displaced posteriorly
79
What are the risks involved with Ludwig Angina?
* Airway occlusion in supine position
* Risk of abscess rupture
80
What is Ludwig Angina associated with?
Trismus
## Footnote
Trismus refers to muscle spasms in your temporomandibular joint.
81
Airway management of Ludwig Angina
* Dependent on severity, CT/MRI findings, and surgical preferences
* Elective tracheostomy for an I & D
* Nasal fiberoptic intubation
82
What are the symptoms of laryngeal trauma?
* Abrasions
* Discoloration
* Indentation
* Pain in larynx region
* Dyspnea / Dysphagia / Dysphonia
* Hoarseness / Stridor
* Hemoptysis
* Subq emphysema
83
Laryngeal Trauma Anesthesia Considerations
* Avoid cricoid pressure d/t risk of crico-tracheal separation
* Airway Dependent on the severity of symptoms
* Tracheostomy may be the best option to secure the airway
* If Subq emphysema is present avoid mask ventilation, just RSI them
84
What is the triad to operation room fire
* Fuel
* Oxidizer
* Ignition Source
85
What can be a source of fuel in the OR?
* Alcohol skin preps
* Drapes/ gowns
* Gauze, sponges
* Hair/ skin
* ETT, N/C
* Intestinal Gases
86
What can be ignitions in the OR?
* Bovie
* Fiberoptic light source
* Drills
* Defibrillators
87
What can be oxidizers in the OR?
* O2
* N2O
88
Prevention of Airway Fire during an ENT procedure
* Maintain O2 ≤ 30% using O2 / air
* Avoid N2O
* Use laser safe ETT / use dye & NS in cuff
* Have 50 mL NS syringe readily available to extinguish fire
* Have 2nd ETT available to reintubate in case of fire
* Inform surgical team if high FiO2 required
89
Management of Airway Fire
* STOP procedure & call for HELP!!
* Remove burning ETT & place in H2O
* Stop ventilation
* Discontinue O2 & N2O (if used)
* Remove sponges & other flammable material from airway
* Pour saline in airway
* Use CO2 fire extinguisher
90
Management of Post Airway Fire
* Re-establish ventilation
* Avoid oxidizer-enriched environment if possible
* Examine ETT for potential fragments retained in airway
* Consider bronchoscopy
91
Management of Non-Airway Fire
* Stop flow of airway gases
* Remove drapes & all burning/flammable materials
* Extinguish burning materials with saline
* Use CO2 fire extinguisher if needed
92
Management of Post Non-Airway Fire
* Maintain ventilation
* Assess for inhalation injury if patient not intubated
* Assess for burns
93
The procedure used in patients with head and neck cancer to search for vocal cord lesions, obtain tissue biopsies, and monitor for tumor recurrence.
Panendoscopy
