Anesthesia for ENT surgeries part 2 Flashcards
Common ENT procedures include
middle ear procedures myringotomy tonsillectomy & adenoidectomy nasal procedures thyroid surgery cleft palate & lip dental restoration trauma radical neck dissection
Describe nerve monitoring for ENT cases
meticulous identification and preservation of cranial nerves
Nerves most often monitored include
facial (VII)
recurrent & inferior laryngeal nerves (X)
vagus nerve (X)
spinal accessory nerve (IX)
When performing nerve monitoring, neuromuscular blocker can be used at
induction & intubation only
- remifentanil 0.05-0.2 mcg/kg/min.
- TIVA
- nitrous oxide
Myringotomy is
tube placed in the tympanic membrane reducing middle ear pressure
The indication for myringotomy is
chronic otitis media- fluid in ear
recurrent otitis media- three or more acute infection in a six month period (four in a 1 year period)
accompanying URI are common
Do you cancel a myringotomy for rhinorrhea?
Typically sick kids so if they have some mild symptoms then it is okay to continue with surgery
Anesthetic considerations for myringotomy includes
short operations- sedatives may outlast procedure
mask induction- assisted ventilation throughout procedure
antibiotic and steroids placed in ear
-mild pain medications given orally or rectally
Indications for pediatric T&A include:
recurrent infections
airway obstruction
Indications for adult T&A include:
OSA
UPP (uvulopalatopharyngoplasty)
comorbidities- CHF
Induction for tonsillectomy & adenoidectomy include
pediatric vs. adult- inhalation vs. intraveous oral RAE tube- consider reinforced Cuffed vs. un-cuffed secure ETT midline eye protection
Anesthetic considerations for T&A include
mouth gag HOB turned medications throat pack orogastric suction EBL- 4 mL/kg IV fluids
Emergence considerations for T&A include:
protect airway reflexes
reduce risk of laryngospasm
minimize coughing- topical vs. intravenous lidocaine
Postoperative considerations for T&A include:
pediatric position- side lying with head slightly down
adult position- high sitting
Post-tonsillectomy can require surgery for
rebleeding (0.3-0.6% of cases)
75% occur within first 6 hours
Anesthetic considerations for return T&A bleed include:
hypovolemic- H&H, T&S, IV placement preop
Full stomach- RSI
Septoplasty can be performed to
correct deformities of nasal septum
Rhinoplasty can be performed to
repair or reshape the nose
cosmetic
airway restoration
Nasal fractures can be
closed reduction (MAC) open reduction (more invasive- ETT vs. LMA)
The “middle ear” refers to the
air-filled space between the tympanic membrane & oval window
Common surgeries of the middle ear in adults & children include:
tympanoplasty
staphedectomy or ossiculoplasty
mastoidectomy
cochlear implants
Surgical considerations for middle ear procedures include:
congenital defects, trauma, treatment of disease
-bloodless field
microsurgery
Anesthetic considerations for middle ear procedures include:
general anesthesia- avoid nitrous oxide, muscle relaxants are avoided
local anesthesia- ability to test hearing during surgery
PONV common
controlled hypotension
deep extubation
Tympanoplasty is performed for
a perforated eardrum
The approach for tympanoplasty can be
post auricular- posterior auditory canal
or
temporal fascial graft- ossicular chain abnormalities repaired with prosthesis
Mastoidectomy is performed for
mastoid cells are “open air”
-indications: cholesteatoma or mastoiditis
The approach for mastoidectomy include
entry through post auricular region
Anesthetic considerations for mastoidectomy include
avoid nitrous oxide & muscle relaxation
The largest endocrine gland in the body is the
thyroid
-blood supply is via carotid arteries
Indications for thyroid surgery include
thyrotoxicosis
malignancies
RLN & external branch of SLN course along _____ of the thyroid
lateral lobes
-associated with movement of intrinsic muscles of the larynx
Anesthetic considerations of thyroid surgery (preop) include
preop- euthyroid, airway assessments b/c goiters can compromise airway status, medications- thyroid & beta blockers
Anesthetic considerations for thyroid surgery include:
regional anesthetic- combined deed & spinal cervical plexus block
direct acting vasopressor- phenylephrine
“Rose” position with arms tucked- second IV
eye protection- goggles
Intraoperative anesthetic considerations for thyroid surgery include
general endotracheal anesthesia
- nerve integrity monitor (NIM) EMG endotracheal tube
- electrodes contact right & left vocal cords
Postoperative anesthetic considerations for thyroid surgery involve
hypocalcemia- signs & symptoms develop within 24-96 hours
- perioral numbness & tingling
- abdominal pain
- extremity paresthesia
- tetany
- laryngospasm
- QT prolongations
- mental status changes & seizures
- Chvostek sign
Postoperative anesthetic considerations for thyroid surgery include:
RLN damage- unilateral more common
-hoarseness
bilateral more serious- biphasic stridor, dyspnea, respiratory distress, aphonia
hematoma- airway obstruction & asphyxiation
One of the most common craniofacial abnormalities is
cleft palate & lip
1:7000
The facial bones fuse by
9th week of development
Up to 30% of those with cleft palate & lip have other congenital anomalies such as
Down syndrome
Pierre Robin
Treacher Collins
These present airway issues d/t small mouth opening, large tongue, micrognathia
Cleft palate & lip involve a
two-stage repair
three months- cleft lip repair with primary tip rhinoplasty
eight months- closure of the hard palate
Preoperative anesthetic considerations for cleft palate & lip include
Rules of ten: >10 weeks of age weight- 10 pounds hemoglobin 10 g WBCs <10,000
Intraoperative anesthetic considerations for cleft palate & lip include
standard induction
oral RAE tube (laryngoscopy can be tricky)
remove air from all lines
eye protection
Postoperative anesthetic considerations for cleft palate & lip include
suture placed through tip of the tongue
-acts as an oral airway
-prevents damage to palatal repair
suction prior to extubation- reduce oral secretions & potential for laryngospasm
consider mittens or arm boards so they don’t disruption suture lines or surgery
Dental restoration can be performed under
general anesthesia for multiple reasons: not appropriate for office visit rampant cavities history of cerebral palsy or Down syndrome uncooperative
Anesthetic considerations for dental restoration include preoperative
oral midazolam (0.5 mg/kg) intramuscular ketamine (3-4 mg/kg)
Intraoperative anesthetic considerations for dental restoration include
standard induction nasal intubation-oxymetazoline spray, warmed RAE tube, nasal trumpet dilation throat pack orogastric suction deep extubation
The goal of trauma is to
secure the airway without causing additional damage or compromising ventilation
Airway obstruction in trauma can be related to:
edema, bleeding, intraoral fractures, nasal passage injury, foreign bodies
Airway management for trauma depends on
the situation
In cases of severe face or neck trauma, consider
retrograde intubation
jet ventilation via cricothyrotomy
emergent tracheostomy
Injuries to the head & neck may include
cervical or cranial injury as well so consider in-line stabilization
LeFort determined common fracture lines along the
maxilla & face
A LeFort 1 fracture is a
horizontal fracture extending from the floor of the nose and hard palate through the nasal septum
A LeFort II fracture is a
triangular fracture running from the bridge of the nose, through the medial and inferior wall of the orbit, beneath the zygoma & through the lateral wall of the maxillar
A LeFort III fracture
separates the midfacial skeleton from the cranial base, traversing the root of the nose, ethmoid bone, eye orbits & sphenopalatine fossa
Anesthetic considerations for trauma include
avoid nasotracheal intubation
consider other trauma (cervical, thoracic, & abdominal)
correct ABCs before addressing facial trauma
consider remaining intubated
awake intubation- maintain airway reflexes
cutting tools attached to the patient or available at the bedside
anticipate extensive blood loss- T&C patient, deliberate hypotension if tolerated
Radical neck dissection is the
resection of cancerous tumors from head & neck
Frequent comorbidities of radical neck dissection include
elderly, smoking, ETOH abuse, cardiovascular disease, history of radiation therapy
Anesthetic considerations for radical neck dissection include
airway management- CT results, consul surgeon, preoperative exam
preoperative labs- including type & cross
two large bore IVs (consider central venous access)
arterial line- tight blood pressure control, lab analysis
Additional anesthetic considerations for radical neck dissection includes
muscle paralysis controlled hypotension minimize vasoconstrictors- flap perfusion intake & output- colloid vs. crystalloid vagal response- anticholinergic
Radical neck dissection may require an
intraoperative tracheostomy or laryngectomy
hyper-oxygenate patient
When performing a radical neck dissection it is important to move
ETT to level above transection
- once tracheostomy is in place verify ventilation & remove ETT
- connect tracheostomy to ventilator
- surgeon will suture in place
Postoperative considerations for a radical neck dissection include
tracheostomy care controlled ventilation chest radiography- rule out pneumothorax monitor for laryngeal edema ICU- potential edema, fluid shifts, altered ventilation, & extensive anesthesia time
The essential goals of ENT surgery include:
- thorough knowledge of airway anatomy
- selecting & preparing for the appropriate airway technique
- preventing & managing airway complications
- producing brief & selective relaxation with potential for rapid recovery
- omitting neuromuscular relaxation for select cases
- maintaining cardiovascular stability
- preventing and/or containing airway fires
- minimizing intraoperative blood loss
- minimizing adverse responses from carotid sinus manipulation
- prevent & treat postsurgical airway obstruction
- avoid and/or limit use of nitrous oxide
