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Mar: Sem 6 - Principles B > Anesthesia for Ear, Nose, and Throat (ENT) > Flashcards

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)

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2
Q

The Recurrent Laryngeal Nerves do NOT provide innervation to these larynx structures.

A
  • Cricothyroid
  • Inferior pharyngeal constrictor muscles
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3
Q

The Recurrent Laryngeal Nerves will provide sensory innervation to what structures?

A
  • Sensory below the vocal cords
  • Sensory of the upper trachea
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4
Q

Internal laryngeal nerve (branch of superior laryngeal nerve) will provide sensory to what structure?

A

Sensory above vocal cords

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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
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6
Q

Presentation of bilateral injury to the RLN.

A
  • Dyspnea
  • Stridor
  • Full airway obstruction from a bilateral vocal cord in paramedian positioning.
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7
Q

What intervention will be indicated in a patient with bilateral RLN damage?

A

Tracheostomy

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8
Q

What are the two branches of the Superior Laryngeal Nerve?

A
  • External Branch
  • Internal Branch
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9
Q

What is the external branch of the SLN responsible for?

A

Motor to cricothyroid muscle & inferior pharyngeal muscles

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10
Q

What is the internal branch of the SLN responsible for?

A

Sensory to laryngeal mucosa above vocal cords

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11
Q

What are examples of external ear surgery?

A
  • Foreign body removal
  • Removal of tumors
  • Cancers
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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

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13
Q

What needs to be avoided for middle ear procedures?

A

Nitrous Oxide

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14
Q

What ear procedure is most commonly performed in children

A

Myringotomy with tube placement.

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15
Q

Anesthesia for Myringotomy

A

Sevoflurane mask anesthesia

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16
Q

What procedure is done to treat otosclerosis?

A

Stapedectomy

GETA

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17
Q

What are examples of inner ear surgery?

A
  • Cochlear implant
  • Surgery to Endolymphatic sac or Labyrinth
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18
Q

Most patients involved in ear procedures are prone to _________.

A

PONV

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19
Q

Why do you want controlled hypotension with a mastoidectomy?

A

To control bleeding

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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)
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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)
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22
Q

Anesthesia Consideration for Stapedectomy

A
  • Laser precautions
  • Facial nerve monitoring
  • Deliberate hypotension
  • PONV (use at least 3 antiemetics)
  • Gentle emergence (Deep extubation?)
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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
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24
Q

What preop assessments are focused on nasal procedures?

A
  • OSA
  • HTN
  • Samter Triad

Samter Triad = Nasal polyps , Asthma, Sensitivity to ASA/NSAIDS

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25
Q

What is the Samter Triad. What is the significance?

A
  • Nasal polyps
  • Asthma
  • Sensitivity to ASA/NSAIDS

The combination of these three factors may produce DEADLY bronchospasms

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26
Q

How long should ASA and NSAIDs be held before nasal surgery?

A

1 – 2 weeks preop

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27
Q

What is the purpose of a throat pack for nasal surgery?

A

Prevents blood & surgical debris in pharynx & larynx

Document throat pack time in & out

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28
Q

What are the three vasoconstrictors used in nasal surgery?

A
  • Cocaine 4%
  • Phenylephrine
  • Oxymetazoline (Afrin)
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29
Q

What is the MOA of Cocaine 4%?
What is the dose?

A
  • Blocks reuptake of norepinephrine at sympathetic nerve terminals
  • Do not exceed 1.5 mg/kg
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30
Q

Contraindication of Cocaine 4%

A
  • CAD
  • HTN
  • Pt on MAOIs
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31
Q

Dose of Phenylephrine used for nasal procedures

A
  • Solo or w/lidocaine
  • Initial dose < 500 mcg

Treat HTN with direct vasodilators or α-receptor antagonists

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32
Q

What drugs should be avoided if phenylephrine is used for nasal surgery?

A

β-adrenergic blocker and CCB should be avoided because they may worsen CO and produce pulmonary edema

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33
Q

MOA of Oxymetazoline.

Dose.

A
  • Selective α1-agonist and partial α2-agonist imidazoline-derivative
  • 0.05% solution x 3 sprays
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34
Q

Contraindication of Oxymetazoline

A

Patients taking monoamine oxidase inhibitors

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35
Q

Emergence Consideration for Nasal Surgery

A
  • Gastric suctioning before emergence
  • Prevent coughing / bucking (↑ bleeding)
  • Avoid pressure on face (lift that jaw up to the mask)
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36
Q

What are examples of Endoscopic Sinus Surgeries?

A
  • Nasal polyposis
  • Sinusitis
  • Epistaxis control
  • Tumor excision
  • Foreign body removal
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37
Q

Anesthesia Considerations for Endoscopic Sinus Surgery

A
  • Controlled hypotension (blood free field)
  • TIVA (Propofol / remifentanil)
  • Smooth wake-up
  • SGA vs ETT (oral rae)
  • Nasal Vasoconstriction meds
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38
Q

How will the patient be positioned if undergoing an image-guided endoscopic sinus surgery?

A

A special headset on the patient requires the bed to be turned 180 degrees away from the anesthesia provider.

39
Q

Potential Complications for Endoscopic Sinus Surgery

A
  • Orbital hematoma
  • Blindness from orbital trauma
  • Optic nerve injury
  • CSF leak
  • Carotid or ethmoid artery invasion
  • Cranial cavity entry
  • Hemorrhage
40
Q

When will a patient have a Tonsillectomy performed?

A
  • Tonsillar hyperplasia
  • Recurrent tonsillitis
  • Malignancy
41
Q

When will a patient have an Adenoidectomy performed?

A

Hyperplasia causing nasopharyngeal obstruction

42
Q

Lymphoid tissue posterior to the nasal cavity in the roof of the nasopharynx

A

Adenoids

43
Q

When pre-oping for a Tonsillectomy/Adenoidectomy, if the patient has OSA. What other associated issues would the anesthesia provider investigate?

A
  • Cor pulmonale
  • Pulmonary HTN
  • RV hypertrophy
  • Cardiomegaly
44
Q

Tonsillectomy/Adenoidectomy Anesthesia Considerations

A
  • 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
Q

Tonsillectomy/Adenoidectomy complications

A
  • Post-op hemorrhage
  • Usually occurs within 6 hours
  • May occur days later
46
Q

Patients with nasal polyps, asthma, and sensitivity to aspirin or at risk for ________ during their procedure.

A

Bronchospasm

47
Q

OSA Surgery Anesthesia Considerations

A
  • Possible difficult ventilation & intubation
  • Oral RAE tube – taped midline
  • Redundant tissue, macroglossia
  • Minimize opioids
  • Postop hypoxia
  • Dexamethasone to reduce airway edema (10 mg)
48
Q

Patients with OSA have an increase in postoperative obstructive episodes, peaking on postoperative day ____ and returning to preoperative levels after a week

A

Day 3

49
Q

A panendoscopy is a combination of what three procedures?

A
  • Laryngoscopy
  • Bronchoscopy
  • Esophagoscopy
50
Q

Anesthesia Considerations for Panendoscopy

A
  • 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
Q

What are the pros of using Microlaser/ Laser Tubes?

A
  • All metal ETT
  • Airway protection
  • Ventilation control
  • EtCO2 measurement
  • Double cuff
52
Q

What are the cons of using Microlaser/ Laser Tubes?

A
  • Higher than usual ventilation pressures (narrow diameter)
  • Challenging surgical access
  • Tube ignition is possible when the laser is in use
53
Q

Decribe how an anesthesia provider performs supraglottic jet ventilation.

A
  • High-pressure O2 “breaths” @ 20 – 50 PSI
  • 1 second on / 3 seconds off
54
Q

Type of sedation required for jet ventilation

A

TIVA

55
Q

Disadvantages of Jet Ventilation

A
  • Barotrauma possible (PSI >50)
  • No measurement of Vt or EtCO2
  • Suboptimal for obese pts
56
Q

Signs and symptoms of thyrotoxicosis

A
  • Sinus tachycardia / A-fib
  • MI / CHF
  • Nervousness/tremulousness
  • Insomnia
  • Heat intolerance
  • Weight loss
57
Q

Anesthesia considers if a patient has a goiter.

A
  • Deviation of larynx
  • Tracheal compression causing airway stenosis
  • Airway collapse after induction of anesthesia & muscle relaxant administration
  • Horner syndrome
  • SVC obstruction
58
Q

How is hypercalcemia secondary to hyperparathyroidism treated in pre-op?

A
  • Fluids
  • Furosemide
  • Bisphosphonates
59
Q

Parathyroidectomy Lab considerations

A
  • Baseline Ca++ & PTH
  • Redraw Ca++ & PTH 10 minutes after excision of parathyroid
  • Consider an arterial line
60
Q

Thyroidectomy & Parathyroidectomy Anesthesia Considerations

A
  • 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
Q

Between what tracheal rings will a tracheostomy be performed?

A

B/w 2nd and 3rd tracheal ring

62
Q

Tracheostomy Anesthesia Considerations

A
  • 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
Q

When will a neck dissection & laryngectomy be performed?

A

Prevention/treatment of head & neck CA

64
Q

Anesthesia considerations for neck dissection & laryngectomy

A
  • 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
Q

What are Le Fort Fractures?
How many types are there?

A
  • Midfacial fractures
  • 3 major types (I, II, and III)
66
Q

Describe a Le Fort I fracture

A
  • Horizontal fx involving inferior nasal aperture
  • Separates teeth and lower maxillary components from upper facial structures
67
Q

Describe a Le Fort II fracture

A

Triangular fracture with the fracture line across the nose,
below the infraorbital rim and through the entire lower maxilla

68
Q

Describe a Le Fort III fracture

A
  • 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
Q

Anesthesia Considerations for Le Fort fractures

A
  • 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
Q

When will a patient have a Le Fort Osteotomy?

A
  • Correct maxillary deformities
  • Corrects malocclusion of teeth by movement of maxilla and/or mandible
71
Q

Anesthesia Considerations for Le Fort Osteotomy?

A
  • Young patients (< 30 yo)
  • Nasal intubation
  • Deliberate hypotension
  • Minimal fluid resuscitation
  • Opioids / multimodal PONV prophylaxis
  • Awake extubation
  • Jaws wired or tightly banded
72
Q

Interventions for Allergic Reaction Angioedema

A
  • Antihistamines
  • Steroids
  • H2 antagonist
  • Epinephrine
  • Intubation (use a smaller tube)
73
Q

At what age is acute epiglottis most common?

A

2 to 6 years old

74
Q

Cause of acute epiglottis

A

H-influenza

75
Q

Signs and Symptoms of Acute Epiglottis

A
  • Sore throat
  • Dysphagia
  • Drooling
  • Fever
  • Muffled voice
  • Open-mouth tripod position
  • Stridor / respiratory distress
  • Total airway obstruction
76
Q

Pediatric Management of Acute Epiglottis

A
  • Prevent crying
  • Calm inhalation anesthesia induction
  • Maintain spontaneous respiration
  • Consider smaller ETT
  • Rigid bronchoscopy
  • Surgical airway may be necessary
77
Q

Adult Management of Acute Epiglottis

A
  • Assessment of disease
  • Oropharyngeal exam
  • Fiberoptic nasopharyngoscopy
  • ICU admission
  • Inhaled mist medication/ steroids/ abx
  • Awake fiberoptic intubation (safetest option)
78
Q

What is Ludwig Angina

A
  • Floor of mouth infection
  • Starts with mandibular molars
  • Spreads to submandibular, sublingual, submental, and buccal spaces
  • Tongue displaced posteriorly
79
Q

What are the risks involved with Ludwig Angina?

A
  • Airway occlusion in supine position
  • Risk of abscess rupture
80
Q

What is Ludwig Angina associated with?

A

Trismus

Trismus refers to muscle spasms in your temporomandibular joint.

81
Q

Airway management of Ludwig Angina

A
  • Dependent on severity, CT/MRI findings, and surgical preferences
  • Elective tracheostomy for an I & D
  • Nasal fiberoptic intubation
82
Q

What are the symptoms of laryngeal trauma?

A
  • Abrasions
  • Discoloration
  • Indentation
  • Pain in larynx region
  • Dyspnea / Dysphagia / Dysphonia
  • Hoarseness / Stridor
  • Hemoptysis
  • Subq emphysema
83
Q

Laryngeal Trauma Anesthesia Considerations

A
  • 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
Q

What is the triad to operation room fire

A
  • Fuel
  • Oxidizer
  • Ignition Source
85
Q

What can be a source of fuel in the OR?

A
  • Alcohol skin preps
  • Drapes/ gowns
  • Gauze, sponges
  • Hair/ skin
  • ETT, N/C
  • Intestinal Gases
86
Q

What can be ignitions in the OR?

A
  • Bovie
  • Fiberoptic light source
  • Drills
  • Defibrillators
87
Q

What can be oxidizers in the OR?

A
  • O2
  • N2O
88
Q

Prevention of Airway Fire during an ENT procedure

A
  • 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
Q

Management of Airway Fire

A
  • 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
Q

Management of Post Airway Fire

A
  • Re-establish ventilation
  • Avoid oxidizer-enriched environment if possible
  • Examine ETT for potential fragments retained in airway
  • Consider bronchoscopy
91
Q

Management of Non-Airway Fire

A
  • Stop flow of airway gases
  • Remove drapes & all burning/flammable materials
  • Extinguish burning materials with saline
  • Use CO2 fire extinguisher if needed
92
Q

Management of Post Non-Airway Fire

A
  • Maintain ventilation
  • Assess for inhalation injury if patient not intubated
  • Assess for burns
93
Q

The procedure used in patients with head and neck cancer to search for vocal cord lesions, obtain tissue biopsies, and monitor for tumor recurrence.

A

Panendoscopy

Mar: Sem 6 - Principles B (14 decks)

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