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AS - N931 Advanced Principles of Anesthesia > ENT > Flashcards

ENT Flashcards

1
Q

Trigeminal Nerve

A 
Cranial nerve V
Provides sensory innervation to the face
Three divisions:
- Ophthalmic V1
- Maxillary V2
- Mandibular V3
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2
Q

Glossopharyngeal Nerve

A

Cranial nerve IX
Provides sensory innervation to posterior 1/3 tongue, oropharynx, vallecula, & anterior epiglottis
Gag reflex - affect limb (receives stimulation)

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3
Q

Facial Nerve

A

Cranial nerve VII
Located at tragus
Supplies motor & sensory function to the face - facial expressions
Six major branches:
- Anterior (temporal, zygomatic, buccal, & mandibular)
- Inferior (cervical)
- Posterior (posterior auricular)

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4
Q

Vagus Nerve

A

Cranial nerve X
Superior laryngeal nerve
- Internal branch SIS (sensory innervation from posterior epiglottis to vocal cord folds)
- External branch SEM (motor innervation BELOW the vocal cords)
Recurrent laryngeal nerve
- Sensory innervation BELOW the vocal folds & trachea
- Motor innervation to ALL intrinsic laryngeal muscles
R RLN loops under subclavian artery
L RLN loops under aorta

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5
Q

ENT Anesthetic Considerations

A 
Preop airway assessment
Eye protection
ETT placement - downsize, reinforced, or RAE
Fire resistant ETTs (metal-impregnated or fire-resistant)
HOB rotated 90-180° 
- HME connector
- IV extension tubing
Nerve monitoring NIMs ETT w/ electrodes
Corticosteroids ↓airway swelling
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6
Q

PONV

A

ENT surgeries associated w/ ↑incidence (middle ear)
Blood accumulation in oropharynx & swallowed
- Throat pack
- OG suctioning prior to extubation
Multi-modal approach to prevent/treat

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7
Q

How many wavelengths do lasers have?

A

Only one

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8
Q

Laser Safety

A 
Warning signs placed outside OR
Eye protection - providers & patient
Lens dependent on laser being used
Goal FiO2 < 30%
Avoid nitrous oxide
Fill Ett cuff w/ saline or methylene blue
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9
Q

Airway Fire TRIAD

A
  1. Oxidizer - oxygen or nitrous oxide
  2. Fuel - alcohol-based prep solutions, surgical drapes, sponges, towels, gauze, ETT/LMAs, or organic material
  3. Ignition - lasers, fiber-optic lights, Bovie or ESUs
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10
Q

Airway Fire Prevention

A 
Fire-resistant (metal-impregnated) ETT
Saline-filled ETT cuff
↓FiO2 < 30% 
Avoid nitrous oxide
Use water-based lubricants
Avoid paper drapes
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11
Q

Airway Fire Treatment

A 
Extinguish fire
↓FiO2 RA 21% 
Stop laser or Bovie
Remove ETT
Re-secure airway
Assess damage (bronchoscopy)
Lavage treatment
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12
Q

Endoscopy

A

Laryngoscopy, bronchoscopy, or esophagoscopy
Flexible or rigid scope
Consider Lidocaine, Remifentanil, & Esmolol to block SNS stimulation
Minimal muscle relaxation - do not re-dose after induction
Airway shared w/ surgeon
- ETT 5.0-6.0mm
- Intermittent apnea (hold ventilation)

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13
Q

Jet Ventilation

A

Manual ventilation w/ hand-valve or mechanical device
High-velocity jet stream inspiration 60psi
Passive expiration ↑risk air trapping when mass lies above gas delivery level → SQ emphysema or pneumothorax
TIVA anesthesia to relax chest wall
Contraindicated in full stomach, hiatal hernia, or trauma

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14
Q

High-Frequency Jet Ventilation

A

When limited access to airway
Via needle, ETT, catheter, or side-port on rigid bronchoscope
Low Vt ↑RR
Difficult to maintain oxygenation in certain patient populations

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15
Q

Sinus Surgery

Indications

A

Sinus obstruction - infection, polyps, or tumors
- Polyps associated w/ asthma & cystic fibrosis (reactive airway & allergies)
Sinusotomies

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16
Q

Sinus Anesthetic Considerations

A 
GA vs. MAC
ETT vs. LMA
Avoid nitrous oxide
↓bleeding 
- Mild hypotension 
- Vasoconstriction (Phenylephrine)
- Deep anesthesia
Hyperventilate to maintain ETCO2 25-30mmHg
Consider Mannitol 25-50mg IV
Deep extubation to prevent coughing
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17
Q

Sinus Surgery

Complications

A

Dural puncture

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18
Q

What is the leading cause of death among children < 4yo?

A

Foreign body aspiration

Beads, coins, pins, small toys

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19
Q

Foreign Body Aspiration S/S

A

Wheezing
Coughing
Aphonia - unable to speak
Cyanosis

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20
Q

Foreign Body Aspiration

Treatment

A

Depends on size and object location
Larynx - laryngoscopy & removal w/ Magill forceps
Distal larynx or trachea - rigid bronchoscopy
- Mouth guard to avoid injury
- Tracheal tears possible d/t object
- Inadequate ventilation

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21
Q

Foreign Body Aspiration

Anesthetic Considerations

A

Inhalational induction w/ 100% FiO2
Maintain spontaneous respirations
Administer antisalagogue, H2 blocker, & pro-kinetic
Avoid coughing, bucking, or straining to prevent tracheal tear
Full stomach → RSI
- Prepared to perform cricothyrotomy or tracheotomy
Vagal stimulation during procedure

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22
Q

Foreign Body Aspiration

Postop Considerations

A

Return airway reflexes
Edema possible up to 24 hours post procedure
- Test cuff link prior to extubation
Supportive measures - racemic Epi, bronchodilators, steroids
Prevent airway edema & swelling

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23
Q

Myringotomy

A

Ear tubes

Tubes placed in the tympanic membrane reducing middle ear pressure

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24
Q

Chronic Otitis Media

A

Fluid present in the ear

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25
Recurrent Otitis Media
3+ acute infections w/in 6mos or 4 in 1 year period | Commonly accompanies upper respiratory infections
26
Myringotomy | Anesthetic Considerations
Short operations - sedation outlasts procedure Mask induction w/ assisted ventilation throughout procedure Antibiotics & steroids placed in ear Mild pain medications PO or rectal admin NO IV ACCESS
27
Tonsillectomy & Adenoidectomy
Pediatric - recurrent infections or airway obstruction | Adults - OSA, uvulopalatopharyngoplasty (UPP), or comorbidities (biventricular CHF)
28
T&A Anesthetic Considerations
``` Oral RAE tube - Consider reinforced Secure ETT midline Eye protection Mouth gag to protect teeth HOB rotated Throat pack - ensure removed OG suction EBL 4mL/kg IV fluids ↑PONV risk ```
29
T&A Emergence Considerations
``` Protect airway reflexes Reduce laryngospasm risk Minimize coughing - Lidocaine topical or IV Adenoids - deep extubation T&A - awake extubation w/ protective reflexes present ```
30
T&A Postop Considerations
Pediatric position - side-lying w/ head slightly down Adult position - high sitting to prevent laryngospasm or respiratory distress Post-tonsillectomy requiring surgery RSI d/t bleeding into stomach - Hypovolemic - Type & screen - Hgb/Hct - Place IV preop
31
Nasal Procedures
Septoplasty - correct nasal septum deformities Rhinoplasty - airway restoration or cosmetic nasal repair/re-shaping Nasal fractures - open or closed reduction
32
Middle Ear
Air-filled space b/w tympanic membrane & oval window
33
Middle Ear Procedures
Tympanoplasty - perforated eardrum Stapedectomy or ossiculoplasty Mastoidectomy Cochlear implants
34
Middle Ear | Anesthetic Considerations
GA - avoid nitrous oxide & muscle relaxants Local anesthesia allows audiologist to test hearing during surgery PONV common Controlled hypotension Deep extubation
35
Tympanoplasty
``` Perforated eardrum Post-auricular approach - Posterior auditory canal Temporal fascial graft - Ossicular chain abnormalities repaired w/ prothesis ```
36
Mastoidectomy
Mastoid cells are "open air" Indications include cholesteatoma or mastoiditis Entry through post-auricular region AVOID nitrous oxide & muscle relaxants
37
Thyroid
Largest endocrine gland Blood supply via carotid arteries RLN & SLN external branch course along lateral lobes Indications include thyrotoxicosis or malignancies
38
Thyroid Surgery | Preop Considerations
Euthyroid - labs Thyroid medications β blockers Airway assessment (goiter)
39
Thyroid Surgery | Intraop Considerations
Regional anesthetic - combined deep & superficial cervical plexus block Direct-acting vasopressor (Phenylephrine) "Rose" position w/ arms tucked Place 2nd PIV Eye protection & face padding GETA - nerve integrity monitor NIMs tube (EMG ETT electrodes contact R & L vocal cords) place w/ video laryngoscope
40
Thyroid Surgery | Postop Considerations
Hypocalcemia S/S develop w/in 24-96hrs RLN damage - unilateral or bilateral Hematoma → airway obstruction & asphyxiation
41
Hypocalcemia S/S
``` Perioral numbness & tingling Abdominal pain Extremity paresthesia Tetany Laryngospasm QT prolongation Mental status changes Seizures Chvostek sign ``` Monitor routine Ca2+ levels
42
RLN | Unilateral Nerve Damage
More common | Hoarse voice
43
RLN | Bilateral Nerve Damage
``` EMERGENT Requires airway securement Biphasic stridor Dyspnea Respiratory distress Aphonia ```
44
Cleft Lip & Palate
``` 30% have other congenital anomalies - Down syndrome - Pierre robin (micrognathia) - Treacher collins Requires 2 stage repair 1. Cleft lip repair w/ 1° tip rhinoplasty at 3mos 2. Hard palate closure at 8mos ```
45
What is one of the most common craniofacial abnormalities?
Cleft lip & palate
46
When do facial bones fuse during development?
Week 9
47
Cleft Lip & Palate | Preop Considerations
Age > 10wks old Weigh at least 10lbs Hgb 10g/dL WBC < 10,000/mm^3
48
Cleft Lip & Palate | Intraop Considerations
``` Standard induction Oral RAE tube Potential difficult laryngoscopy Remove air from all lines Eye protection ```
49
Cleft Lip & Palate | Postop Considerations
``` Suture placed through tongue tip - Acts as an oral airway - Prevents damage to palatal repair Suction PRIOR to extubation - ↓oral secretions & laryngospasm risk Consider mittens or armboards to prevent suture disruption ```
50
Dental Restoration
Performed under GA - Not appropriate office visit - Rampant cavities - Down syndrome or cerebral palsy - Uncooperative
51
Dental Restoration | Preop Considerations
Midazolam PO 0.5mg/kg | Ketamine IM 3-4mg/kg
52
Dental Restoration | Intraop Considerations
``` Standard induction Nasal intubation - Vasoconstriction spray - Warm nasal RAE tube - Dilation w/ nasal trumpet - Lidocaine ointment - Phenylephrine lube Throat pack placement OG suction Deep extubation ```
53
Trauma Airway Managment
Severe face or neck trauma - retrograde intubation, jet ventilation via cricothyrotomy, or emergent tracheostomy Cervical injuries C-spine collar
54
Airway Obstruction CAUSES
``` Edema Bleeding Intraoral fractures Nasal passage injury Foreign body ```
55
LeFort
Common fracture lines along the maxilla & face
56
LeFort I
Horizontal fracture extending from nasal floor & hard palate through the nasal septum
57
LeFort II
Triangular fracture from the nasal bridge, through the medial & inferior orbit wall, beneath the zygoma, & through the lateral maxilla wall
58
LeFort III
Separates the midfacial skeleton from the cranial base, traversing the nasal root, ethmoid bone, eye orbits, & sphenopalatine fossa
59
Trauma | Anesthetic Considerations
``` AVOID nasotracheal intubation Consider other trauma - cervical, thoracic, or abdominal 1st ABCs before addressing facial trauma Anticipate extensive blood loss - Type & cross - Controlled hypotension as tolerated Awake intubation (keep 'em breathing) PONV prophylaxis Multi-modal pain Smooth/deep extubation to prevent coughing or bucking ```
60
Radical Neck Dissection
Cancerous tumor resection from head & neck | Frequent comorbidities - elderly, smoker, ETOH abuse, CV disease, radiation therapy history
61
Radical Neck Dissection | Preop Considerations
``` Airway assessment - CT results - Consult surgeon Tracheostomy or laryngectomy Type & cross ```
62
Radical Neck Dissection | Intraop Considerations
``` Consider central venous access Large bore PIV x2 A-line - close BP monitoring & frequent labs Muscle paralysis Controlled hypotension - consider flap implications (requires adequate blood flow) Minimize vasoconstrictors I/O crystalloid vs. colloid Anticholinergics to treat vagal response Hyper-oxygenate patient ETT → trach - Pull ETT back to level above transection - Verify ventilation & remove ETT - Connect trach to ventilator - Sutured in place by surgeon ```
63
Radical Neck Dissection | Postop Considerations
Trach care Controlled ventilation CXR r/o pneumothorax Monitor for laryngeal edema ICU admission: - Edema & fluid shifts - Altered ventilation - Extensive anesthesia time
64
ENT Key Points
- Airway anatomy - Select & prepare appropriate airway technique (communication w/ surgical team) - Prevent & manage airway complications - Select cases no neuromuscular relaxation - Maintain CV stability (controlled hypotension) - Prevent and/or contain airway fires - Minimize intraop blood loss - Minimize adverse responses from carotid sinus manipulation - Prevent & treat post-surgical airway obstruction - Avoid and/or limit nitrous oxide use

AS - N931 Advanced Principles of Anesthesia (17 decks)

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