Ears nose and throat

Question 1

Which of the following laboratory values is increased in patients with untreated hypothyroidism?

Answer 1

Thyrotropin-Patients with hypothyroidism have decreased levels of triiodothyronine (T3) and thyroxine (T4). An increased thyrotropin level is diagnostic of hypothyroidism and normal thyrotropin levels indicate adequate medical control of hypothyroidism.

Question 2

A poorly-controlled hyperthyroid patient is undergoing emergency surgery for an appendectomy. At what point would the patient be most likely to experience a thyrotoxic crisis?

Answer 2

After case is finished

Question 3

Following induction and intubation of a patient with hypothyroidism, the blood pressure falls to 80/40 mmHg. The most appropriate intervention for this patient would be to administer

Answer 3

Ephedrine-in patients with hypothyroidism, the administration of alpha agonists such as phenylephrine could substantially increase the systemic vascular resistance against a heart that has limited capacity to compensate by increasing its contractility. Epinephrine 50 mcg would increase both the SVR and contractility, but a 50 mcg dose may be enough to result in hypertension and arrhythmias. Atropine would serve to increase the heart rate but would not address the issue of blood pressure. The best option for these patients is to administer small (2.5 - 5mg) doses of ephedrine while monitoring filling pressures and the ECG closely.

Question 4

Which of the following laboratory findings would be consistent with a diagnosis of hyperparathyroidism?

Answer 4

The hallmark laboratory finding in hyperparathyroidism is a serum calcium level greater than 5.5 mEq/L or an ionized calcium level greater than 2.5 mEq/L.

Question 5

You are performing a general anesthetic on a patient undergoing a parathyroidectomy. Which of the following signs and symptoms would be most closely associated with hyperparathyroidism?

Answer 5

Shortened QT interval-The principal pathologic feature of hyperparathyroidism resulting in symptoms is hypercalcemia. The elevated serum calcium concentrations can result in a shortened QT interval, prolonged PR interval, hypotonia and skeletal muscle weakness (as opposed to hyperreflexia). Hyperparathyroidism is often associated with hypertension and the influence of parathyroid hormone on the renal excretion of bicarbonate results in increased serum chloride concentrations which results in a mild metabolic acidosis.

Question 6

You have extubated a pediatric patient following tonsillectomy and the patient exhibits inspiratory stridor. You know that inspiratory stridor most commonly represents

Answer 6

inspiratory stridor-inspiratory stridor results from upper airway obstruction. Lower airway obstruction results in expiratory stridor.

Question 7

The ‘Rose’ position for tonsillectomy may be contraindicated in patients with what disorder?

Answer 7

Achondroplasia-The Rose position involves extension of the neck in the supine position with the use of a shoulder roll. Neck extension may be contraindicated for patients with high risk for subluxation of C1 and C2 such as achondroplasia and some patients with Down’s syndrome.

Question 8

All of the following pathologies are associated with sarcoidosis except:
A-cor pulmonae B-Chronic extrinsic restrictive lung Disease-restrictive C-restrictive cardiomyopathy D-Hypercalcemia

Answer 8

Sarcoidosis is associated with diffuse granulomatous lesions resulting in intrinsic restrictive lung disease, cor pulmonale, and restrictive cardiomyopathy which may present as heart block and dysrhythmias. Other classic signs are hypercalcemia, hepatic granulomas, splenomegaly, and involvement of the parotid gland and facial and optic nerves.

Question 9

All of the following are causes of chronic extrinsic restrictive lung disease except:
flail chest, sarcoidsosis, obesity, pectus carinatum

Answer 9

sarcoidosis-Chronic extrinsic restrictive lung disease is often due to deformities of the thoracic cage such as pectus carinatum, pectus excavatum, kyphosis, scoliosis, and flail chest as well as obesity and neuromuscular disorders. Sarcoidosis is a cause of chronic intrinsic restrictive lung disease.

Question 10

During general anesthesia for a parathyroidectomy for relief of hyperparathyroidism, you should monitor the ECG closely for:

Answer 10

shortened QT-Hyperparathyroidism results in hypercalcemia and hypophosphatemia which can distort the ECG resulting in a shortened QT Interval and prolonged PR interval.

Question 11

The most common causative agent of acute epiglottitis is

Answer 11

The most common causative agent in epiglottitis is Haemophilus influenza type B. The condition typically affects children ages 2-6 years. It can rapidly progress from sore throat to dysphagia to complete airway obstruction. The incidence of epiglottitis has increasingly become a disease of adulthood because of the widespread use of the Haemophilus influenza vaccines in children.

Question 12

Which of the following is not true concerning the anesthetic management of a patient with hyperparathyroidism? (select two)

Answer 12

The predominant pathology in a patient with hyperparathyroidism is hypercalcemia. Patients with hypercalcemia may exhibit hypertension, ventricular arrhythmias, prolonged PR interval, shortened QT intervals, and a greater predisposition towards digoxin toxicity. Hypoventilation should be avoided because acidosis increases the ionized calcium level and can worsen the problem. Lactated ringer’s solution contains calcium, therefore normal saline would be the preferred solution.

Question 13

You are consulted by the emergency department for a patient exhibiting inspiratory stridor, drooling, sore throat, dysphagia, tachycardia, fever, and prefers a sitting, sniffing position to breathe easier. You suspect that this patient suffers from

Answer 13

Although this patient exhibits symptoms associated with epiglottitis, the diagnosis is a misnomer. The patient with epiglottitis actually suffers from generalized irritation and severe edema of all of the supraglottic structures. Some academics have even suggested renaming the condition supraglottitis to more accurately reflect the pathology.

Question 14

A patient with morbid obesity lists obstructive sleep apnea in their history. Which of the following conditions would you least expect to associate with sleep apnea?

Answer 14

Anemia-Patients with obstructive sleep apnea typically develop hypercarbia, polycythemia (not anemia), pulmonary hypertension, and right-sided heart failure as a result.

Question 15

Parathyroid hormone

Answer 15

increases blood calcium levels-Parathyroid hormone increases serum calcium levels by promoting the breakdown of bone, regulation of renal calcium excretion, and altering the GI absorption of the mineral. Parathyroid hormone also facilitates the excretion of phosphate. It may be increased in patients with parathyroid dysplasia, hyperplasia, or benign tumor (adenoma) of the gland.

Question 16

Which of the following is not a potential complication of hypoparathyroidism?

Answer 16

The signs and symptoms of hypoparathyroidism (most commonly caused by surgical excision of the gland) are due to the resulting hypocalcemia and include hypotension, congestive heart failure, muscle weakness, cramps, and irritability.

Question 17

All of the following should be avoided in the patient with symptomatic hypoparathyroidism except

Answer 17

ketamine-The symptoms of hypoparathyroidism are due to the underlying hypocalcemia. These patients will have some degree of myocardial depression making etomidate and ketamine appropriate choices for induction. Hyperventilation should be avoided due to the risk of further reducing ionized calcium levels. Sodium bicarb and citrated blood products can also lead to decreases in ionized calcium levels. Finally, careful titration of muscle relaxants in parathyroid dysfunction patients is prudent due to the unpredictable responses that they may elicit.

Question 18

symptoms of hyperparathyroidism

Answer 18

Patients with hyperparathyroidism will exhibit signs and symptoms related to an underlying hypercalcemia (elevated serum ionized calcium level). These signs and symptoms include renal stones, polyuria, hypertension, ventricular arrhythmias, muscle weakness, and osteoporosis. Surgical excision is the standard treatment for the condition.

Question 19

Thymectomy is used to treat

Answer 19

Thymectomies are commonly performed to treat myasthenia gravis patients. This autoimmune disorder appears to regress when the breeding ground for the immune cells responsible for nicotinic destruction is resected. Polymyalgia rheumatica (or ““muscle rheumatism””) is an inflammatory condition that mainly occurs in the elderly; it is associated with giant-cell arteritis. Rhabdomyolysis is the breakdown of muscular tissue due to any cause.

Question 20

Which of the following structures are at the highest risk of damage during a tracheotomy?

Answer 20

cricothyroid muscle-Three cartilages compose the larynx: the epiglottis, the thyroid, and the cricoid cartilage. The cricothyroid membrane stretches between the thyroid and cricoid cartilages. The cricothyroid and vocalis muscles attach to the vocal cords off of these cartilages and are susceptible to damage during the cricothyrotomy procedure. The innominate artery and inferior thyroid veins are also at risk of damage during surgical access to the trachea. Lastly, the recurrent laryngeal nerve is at risk of damage during dissection

Question 21

A patient scheduled for breast reduction surgery has preoperative labwork which demonstrates severe hypothyroidism. You should

Answer 21

Cancel surgery-A patient presenting for elective surgery with uncorrected hypothyroidism should be canceled until further evaluation and correction of the problem (until they are euthyroid). If the patient presents for emergency surgery, thyroid hormone should be administered in an attempt to correct the hypothyroidism if at all possible

Question 22

Which of the following steps would be a prudent approach to reducing the risk of puncturing the endotracheal tube cuff during tracheal dissection for placement of an tracheostomy?

Answer 22

advance tube towards carina-As the surgeon enters the trachea, there is risk of damage to the endotracheal tube cuff from either the scalpel or an electrocautery unit. The most prudent method of reducing this risk is to advance the tube toward the carina so that as the trachea is entered surgically, the cuff is well below the surgical site. Because an inflated cuff is the principal barrier between the high oxygen concentration being delivered to the patient and a source of ignition (the electrocautery unit), deflating the cuff is not advised at this point in the procedure. As the maintenance of a patent airway could be severely compromised at this point in the procedure, it is important not to remove the endotracheal tube until the surgeon has secured the airway.

Question 23

Taking which of the following actions would indicate a proper understanding of the appropriate anesthetic management of a patient undergoing a high tracheal resection?

Answer 23

maintain pt in head down position-During tracheal resection, a high FiO2 should be maintained throughout the case to ensure adequate oxygenation of the functional residual capacity so temporary interruptions in ventilation are tolerated without hypoxia. During this procedure, the resection may be performed around an endobronchial or double-lumen tube and the patient should be kept in the head-down position to prevent aspiration of blood and surgical debris. An arterial line should be placed in the left radial artery to provide continuous monitoring of blood pressure during periods of compression of the innominate artery.

Question 24

A child suspected of having epiglottitis presents to the emergency department. You have been called because the patient’s ventilatory status is declining and airway management may be needed. Which of the following would be the best approach for intubating this patient?

Answer 24

inhalation induction in OR, use 1/2 smaller size ett Because agitation and struggling can result in the dynamic collapse of the airway with subsequent total airway obstruction, care should be taken to keep the patient calm and relaxed. Excessive manipulation of the patient should be avoided and absolutely no attempt to evaluate the airway should be made in the unanesthetized patient. Inhalation induction with the child in the sitting position is acceptable. After the child becomes drowsy, he/she is placed supine and mask ventilated while intravenous access is acquired. Intubation is then performed with a styletted tube using an endotracheal tube that is 1/2 size smaller than normal.

Question 25

What is the most common postoperative complication in the pediatric patient who has undergone tonsillectomy?

Answer 25

Although aspiration and tooth damage can occur due to tonsillectomy, the most common complication following tonsillectomy is bleeding which occurs in 1 out of every 25 patients.

Question 26

A 50% decrease in airflow for more than 10 seconds that occurs more than 15 seconds per hour of sleep that is sufficient to result in a 4% decrease in oxygen saturation is the definition of

Answer 26

hypopnea-Hypopnea is a 50% decrease in airflow for more than 10 seconds that occurs more than 15 seconds per hour of sleep that is sufficient to result in a 4% decrease in oxygen saturation. Apnea is cessation of respiration for at least 10 seconds. Obstructive sleep apnea is characterized by periodic complete or partial obstruction of the airway during sleep with frequent episodes of apnea or hypopnea, and snoring. OHS is a syndrome that results from chronic OSA and occurs in about 5-10% of patients with OSA. It is characterized by obesity, awake arterial hypercapnia, and insufficient alveolar impairment independent of any other pulmonary disease. It progresses to right ventricular failure.

Question 27

Which of the following agents may be administered intravenously to a patient prior to a parathyroidectomy to aid in the identification of parathyroid tissue?

Answer 27

Methylene blue (7.5 mg/kg in 500 mL of NS) may be administered to aid in the identification of parathyroid tissue. Radioactive technetium sestamibi may also be used, either independently or together with methylene blue to help identify parathyroid tissue.

Question 28

A patient with symptomatic hyperparathyroidism is presenting for a parathyroidectomy. What electrolyte disorders would you expect to see in this patient preoperatively? (select two)

Answer 28

hypophosphorous, hypercalcemia

Question 29

Which of the following medications should be continued in the morning of surgery for a patient presenting for parathyroidectomy (select two)

Answer 29

Pamidronate and zolendronic acid are used to treat hypercalcemia and are commonly administered to patients with hyperparathyroidism. These medications should be continued up until the time of surgery. Diuretics such as furosemide are typically not taken the AM of surgery. The antihypertensive clonidine should be continued. The abrupt withdrawal of clonidine can produce rebound hypertension. Ramipril is a long-acting ACE inhibitor that should be withheld prior to surgery to prevent severe hypotension under anesthesia.

Question 30

Hypocalcemia is a common occurrence following a parathyroidectomy. When would you expect the patient to experience the lowest serum calcium levels?

Answer 30

Hypocalcemia can occur in the immediate postoperative period, but the lowest calcium level seen is usually 4-5 days after surgery.

Question 31

Immediately prior to surgical opening of the trachea during a tracheotomy, you should

Answer 31

advance tube

Question 32

what electrolyte abnormality is associated with hypothyroidism

Answer 32

Hyponatremia and impaired free water excretion are common findings in hypothyroidism.

Question 33

Which of the following respiratory changes occurs with hypothyroidism?

Answer 33

The maximum breathing capacity, diffusion capacity, and ventilatory response to hypoxia and hypercarbia are all decreased.

Question 34

What are the ECG changes often seen with hypothyroidism? (select three)

Answer 34

The ECG may exhibit flattened or inverted T waves, low-voltage P waves and QRS complexes, and sinus bradycardia. They are also more prone to the development of ventricular dysrhythmias.

Question 35

What is the only indication for intravenous levothyroxine?

Answer 35

Myxedema coma is the only true indication for intravenous administration of levothyroxine. It is administered as a 300-500 mcg loading dose followed by 50-200 mcg/day. A TSH level of 5.0 mU/L indicates a euthyroid state. Diastolic dysfunction in hypothyroid patients is often reversed by routine treatment with oral levothyroxine.

Question 36

What is the cardinal feature of myxedema coma?

Answer 36

hypothermia-Despite the name, unconsciousness is relatively uncommon in myxedema coma. The cardinal symptom is hypothermia, which may be as low as 80 degrees Fahrenheit.