Awake Fiberoptic Intubation

Question 1

What is the sensory innervation of the nose

Answer 1

Trigeminal nerve

Question 2

Label 1-3

Answer 2

1. Trigeminal
2. Glossopharyngeal
3. vagus

Question 3

What are the branches of vagus supply the upper airway ?

Answer 3

1. Superior laryngeal - internal branch (cricothyroid m) + external branch (sensory above cords)
2. Recurrent laryngeal- sensory below cords and motor to posterior cricoaryteboids m

Question 4

What is the glossopharyngeal suppply

Answer 4

Sensory to valleculla and base of tongue

Question 5

Innervation of the pharynx?

Answer 5

glossopharyngeal nerve. Innervation of the whole pharynx, posterior third of tongue, the fauces, tonsils, and epiglottis is from the glossopharyngeal nerve.

Question 6

Oropharynx

Answer 6

oropharynx is innervated by branches of the vagus, trigeminal, and glossopharyngeal nerves. The posterior third of the tongue, vallecula, and anterior surface of the epiglottis are innervated by the tonsillar nerve (a branch of the glossopharyngeal nerve). The posterior and lateral wall of the pharynx are innervated by the pharyngeal nerve (a branch of the vagus nerve). The tonsillar nerve affects the tonsils. The anterior twothirds of the tongue are innervated by the lingual nerve (branch of the mandibular division of the trigeminal nerve).

Question 7

Larynx

Answer 7

The larynx is innervated by the vagus nerve (Figure 2). Above the vocal cords (base of tongue, posterior epiglottis, aryepiglottic folds, and arytenoids), the internal branch of the superior laryngeal nerve (a branch of the vagus nerve) supplies innervation. For the vocal cords and below the vocal cords, the recurrent laryngeal nerve (a branch of the vagus nerve) is the supplier.

Answer 8

• The greater and lesser palatine nerves provide sensation to the nasal turbinates and posterior two-thirds of the nasal septum.
• The anterior ethmoid nerve innervates the remainder of the nasal passage.
• The glossopharyngeal nerve provides sensory innervation to the posterior third of the tongue, the vallecula, the anterior surface of the epiglottis (lingual branch), the walls of the pharynx (pharyngeal branch), and the tonsils (tonsillar branch).
• The superior laryngeal nerve innervates the base of the tongue, posterior surface of the epiglottis, aryepiglottic fold, and the arytenoids.
• The recurrent laryngeal nerve provides sensory innervation to the trachea and vocal folds.

Question 9

local anesthetic with vasoconstrictor properties

Answer 9

Cocaine

Question 10

Available Cobain concentrations

Answer 10

Cocaine is available as a 5% or 10% solution and in paste form;

Question 11

the maximum recommended dose of cocain

Answer 11

1.5 mg/kg.

Question 12

Cobain contraindications

Answer 12

. It should be used with caution in patients with coronary artery disease, hypertension, and pseudocholinesterase deficiency.

Question 13

Moffett’s solution

Answer 13

The mixture of 
• 2 mL of 10% cocaine, 
• 1 mL 1:1000 adrenaline, 
• 2 mL sodium bicarbonate, 
• 5 mL sodium chloride 
 = 10 mL of Moffett’s solution.

Question 14

Benefits of Moffett’s

Answer 14

• provide local anesthesia,
• vasoconstriction,
• decongestion
• topicalize the nasal mucosa to provide the optimal conditions for nasal intubations.

Question 15

Lidocaine

Answer 15

used local anesthetic for airway topicalization

Question 16

Concentrated for airway topicalization

Answer 16

The 4% solution and 10% spray are most often used

Question 17

Which technique is in picture

Answer 17

McKenzie technique

Question 18

Describe the Mckenzie technique

Answer 18

uses a 20-gauge cannula attached to oxygen bubble tubing via a three-way tap.

The other end of bubble tubing is then attached to an oxygen source, which is turned on to deliver a flow of 2–4 L/min.
As the local anesthetic is slowly administered via a 5-mL syringe attached to the top port of the cannula, a jetlike spray effect is seen, which greatly increases the surface area of the local anesthetic and allows directed topicalization of the nasal and oral mucosa

Question 19

Name the device

Answer 19

Mucosal atomization device

Question 20

spray-as-you-go (SAYGO) technique

Answer 20

the distal end of a 16-gauge epidural catheter is cut 3 cm from the end and then fed through the working channel of a fiberscope.
The Luer lock connector is connected to the proximal end of the catheter and then attached to a 5-mL syringe prepared with 4% lidocaine.
The distal end should protrude out of the fiberscope, so that the tip is just visible.
The local anesthetic is then dripped onto the vocal cords prior to the fiberscope being introduced into the trachea.
This reduces patient discomfort and coughing when the fiberscope and endotracheal tube are introduced into the trachea.

Question 21

Which technique is displayed on the picture

Answer 21

Inhalation of nebulized lidocaine

Question 22

Topical application techniques

Answer 22

Spray from container
Local anesthetic soaked in ribbon gauze
Cotton applicators
McKenzie technique
Mucosal atomization device
Inhalation of nebulized lidocaine
“Spray as you go” via epidural catheter

Question 23

REGIONAL ANESTHESIA TECHNIQUES

Answer 23

glossopharyngeal,
superior laryngeal, and
recurrent laryngeal nerves, as they supply the innervation to the oropharynx and larynx

Question 24

Complications

Answer 24

intravascular injection andnerve damage, and more than one nerve needs to be blocked

Question 25

Landmark Technique glossopharyngeal block

Answer 25

Transoral

Peristyloid

Question 26

Transoral

Answer 26

☆This method avoids the risk of intravascular injection but is not as successful as when the local anesthetic is injected.

For the intraoral approach,
1. Patient requires sufficient mouth opening to allow adequate visualization and access to the base of the posterior tonsillar pillars (palatopharyngeal arch)
2. After adequate topical anesthesia (lidocaine spray) has been applied, the tongue is retracted medially with a
laryngoscope blade or a tongue depressor, allowing access to the posterior tonsillar pillar.
3. Then, using a 22- or 25-gauge needle, 2–5 mL of 2% lidocaine are injected submucosally, after negative aspiration. The point of injection is at the caudal aspect of the posterior tonsillar pillar (approximately 0.5 cm lateral to the lateral edge of the tongue where it joins the floor of the mouth
4. This is then repeated on the other side.
Alternatively, a gauze soaked in local anesthetic can be firmly applied to this region for a few minutes.

Question 27

peristyloid approach

Answer 27

The peristyloid approach aims to infiltrate local anesthetic just posterior to the styloid process where the glossopharyngeal nerve lies.
In close proximity to this is the internal carotid artery, so care must be taken when using this approach.
The patient should be placed in a supine position with the head placed neutrally. The styloid process is located at the midpoint of a line drawn from the angle of the jaw to the tip of the mastoid process. It can be palpated using deep pressure, but this may be uncomfortable for the patient; a needle is inserted perpendicular to the skin, aiming to hit the styloid process. Once contact has been made (usually 1–2 cm deep), the needle should be reangled posteriorly and walked off the styloid process until contact is lost, then 5–7 mL of 2% lidocaine can be injected after negative aspiration.
This is then repeated on the other side.

Question 28

Superior Laryngeal Nerve Block

Answer 28

the patient is placed in the supine position and will need a degree of neck extension to facilitate identification of the hyoid bone.
Once identified, the hyoid bone is gently displaced to the side where the block is to be performed and a 25-gauge needle isinserted from the lateral side of the neck, aiming toward the greater cornu.

Answer 29

The internal approach uses gauze or pledgets soaked in local anesthetic and placed in the piriform fossae using Krause’s forceps. These need to be kept in place for 5-10 minutes to allow sufficient time for the local anesthetic to take effect.

Question 30

Recurrent Laryngeal Nerve Block

Answer 30

the patient should be supine, with the neck extended be identified in the midline, then the palpating finger should be moved in a caudad direction until the cricoid cartilage is palpated. The cricothyroid membrane lies between these two structures, immediately above the cricoid cartilage. The thumb and third digit of one hand should stabilize the trachea at the level of the thyroid cartilage, then a 22 or 20 gauge needle should be inserted perpendicular to the skin with the aim to penetrate the cricothyroid membrane (above the cricoidcartilage) (Figure 12). This should be done with continuous aspiration of the syringe, as the appearance of bubbles will indicate that the needle tip is now in the trachea. At this point, immediately stop advancing the needle; otherwise, the posterior laryngeal wall can be punctured. Rapid injection (and then removal of the needle) of 5 mL of 4% lidocaine will result in coughing, which will help to disperse the local anesthetic and block of the recurrent laryngeal nerve.

Answer 31

Ultrasound can increase the accuracy of the deposition of local anesthetic around the greater cornu of the hyoid bone for the superior laryngeal nerve block and can be used to identify the cricothyroid membrane for translaryngeal blocks.

Question 32

Superior Laryngeal Nerve Block

Answer 32

The hyoid bone can be visualized on ultrasound (Figure 13), and an in-plane technique can be used to deposit local anesthetic around the surface of the greater cornu of the hyoid bone to achieve the block.

Answer 33

Place the transducer probe in the sagittal plane to identify the greater cornu of the hyoid bone; the transducer is then rotated transversely to identify the superior lateral aspect of the thyrohyoid membrane. The superior laryngeal nerve can be seen superficial to the thyrohyoid membrane when the medial aspect of the probe isrotatedcephalad. The internal branch of the superior laryngeal nerve runs along with the superior laryngeal artery, just below the greater cornu of the hyoid bone.

Answer 34

Place the transducer probe in the sagittal plane to identify the greater cornu of the hyoid bone; the transducer is then rotated transversely to identify the superior lateral aspect of the thyrohyoid membrane. The superior laryngeal nerve can be seen superficial to the thyrohyoid membrane when the medial aspect of the probe isrotatedcephalad. The internal branch of the superior laryngeal nerve runs along with the superior laryngeal artery, just below the greater cornu of the hyoid bone.

Answer 35

An alternative approach is to identify the hyoid bone, which appears as a hyperechoic curved bright structure on ultrasound in the midline. If the probe is moved laterally, the greater cornu of the hyoid bone can be seen as a bright structure medial to the superior laryngeal artery. The internal branch of the superior laryngeal nerve runs with the superior laryngeal artery just below the level of the greater cornu of the hyoid bone. Using an in-plane technique, a needle is passed perpendicular to the skin, aiming just below the greater cornu of the hyoid bone.
Then, 1–2 mL of local anesthetic can be injected here after negative aspiration (Figure 14).

Question 36

Translaryngeal Block

Answer 36

Ultrasound can be used to identify the thyroid and cricoid cartilages and the cricothyroid membrane ensuring that the local anesthetic is deposited correctly and a successful translaryngeal block is achieved19

Answer 37

If the probe is placed longitudinally in the midline of the neck, the tracheal rings can be seen. If the probe is then advanced cranially, the cricoid cartilage can be seen next; this is a slightly elongated structure that is larger and more superficial than the tracheal rings. If the probe is further advanced cranially, the thyroid cartilage can be seen. The cricothyroid membrane lies between the caudal border of the thyroid cartilage and the cephalad border of the cricoid cartilage. Keep the probe in the midline with the cricothyroid membrane in the middleof the image seen on the monitor; then, the exact location on the patient’s neck can be marked using a marker pen. Now that the position of the cricothyroid membrane has been located, the translaryngeal block can be performed.

Answer 38

The block can also be performed under real-time sonography by simplytiltingthe probe from the midline to a parasagittal position, keeping the cricoid cartilage in view. The needle entry point should be just cranial to the cricoid cartilage and can be seen on the ultrasound monitor (Figure 16). Once air is aspirated, this confirms that the needle is through the membrane and in the trachea