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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
Q

Recurrent Otitis Media

A

3+ acute infections w/in 6mos or 4 in 1 year period

Commonly accompanies upper respiratory infections

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26
Q

Myringotomy

Anesthetic Considerations

A

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
Q

Tonsillectomy & Adenoidectomy

A

Pediatric - recurrent infections or airway obstruction

Adults - OSA, uvulopalatopharyngoplasty (UPP), or comorbidities (biventricular CHF)

28
Q

T&A Anesthetic Considerations

A 
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
Q

T&A Emergence Considerations

A 
Protect airway reflexes
Reduce laryngospasm risk
Minimize coughing
- Lidocaine topical or IV 
Adenoids - deep extubation
T&A - awake extubation w/ protective reflexes present
30
Q

T&A Postop Considerations

A

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
Q

Nasal Procedures

A

Septoplasty - correct nasal septum deformities
Rhinoplasty - airway restoration or cosmetic nasal repair/re-shaping
Nasal fractures - open or closed reduction

32
Q

Middle Ear

A

Air-filled space b/w tympanic membrane & oval window

33
Q

Middle Ear Procedures

A

Tympanoplasty - perforated eardrum
Stapedectomy or ossiculoplasty
Mastoidectomy
Cochlear implants

34
Q

Middle Ear

Anesthetic Considerations

A

GA - avoid nitrous oxide & muscle relaxants
Local anesthesia allows audiologist to test hearing during surgery
PONV common
Controlled hypotension
Deep extubation

35
Q

Tympanoplasty

A 
Perforated eardrum
Post-auricular approach
- Posterior auditory canal
Temporal fascial graft
- Ossicular chain abnormalities repaired w/ prothesis
36
Q

Mastoidectomy

A

Mastoid cells are “open air”
Indications include cholesteatoma or mastoiditis
Entry through post-auricular region
AVOID nitrous oxide & muscle relaxants

37
Q

Thyroid

A

Largest endocrine gland
Blood supply via carotid arteries
RLN & SLN external branch course along lateral lobes
Indications include thyrotoxicosis or malignancies

38
Q

Thyroid Surgery

Preop Considerations

A

Euthyroid - labs
Thyroid medications
β blockers
Airway assessment (goiter)

39
Q

Thyroid Surgery

Intraop Considerations

A

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
Q

Thyroid Surgery

Postop Considerations

A

Hypocalcemia S/S develop w/in 24-96hrs
RLN damage - unilateral or bilateral
Hematoma → airway obstruction & asphyxiation

41
Q

Hypocalcemia S/S

A 
Perioral numbness & tingling
Abdominal pain
Extremity paresthesia
Tetany
Laryngospasm
QT prolongation
Mental status changes
Seizures
Chvostek sign

Monitor routine Ca2+ levels

42
Q

RLN

Unilateral Nerve Damage

A

More common

Hoarse voice

43
Q

RLN

Bilateral Nerve Damage

A 
EMERGENT
Requires airway securement
Biphasic stridor
Dyspnea
Respiratory distress
Aphonia
44
Q

Cleft Lip & Palate

A 
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
Q

What is one of the most common craniofacial abnormalities?

A

Cleft lip & palate

46
Q

When do facial bones fuse during development?

A

Week 9

47
Q

Cleft Lip & Palate

Preop Considerations

A

Age > 10wks old
Weigh at least 10lbs
Hgb 10g/dL
WBC < 10,000/mm^3

48
Q

Cleft Lip & Palate

Intraop Considerations

A 
Standard induction
Oral RAE tube
Potential difficult laryngoscopy
Remove air from all lines
Eye protection
49
Q

Cleft Lip & Palate

Postop Considerations

A 
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
Q

Dental Restoration

A

Performed under GA

  • Not appropriate office visit
  • Rampant cavities
  • Down syndrome or cerebral palsy
  • Uncooperative
51
Q

Dental Restoration

Preop Considerations

A

Midazolam PO 0.5mg/kg

Ketamine IM 3-4mg/kg

52
Q

Dental Restoration

Intraop Considerations

A 
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
Q

Trauma Airway Managment

A

Severe face or neck trauma - retrograde intubation, jet ventilation via cricothyrotomy, or emergent tracheostomy
Cervical injuries C-spine collar

54
Q

Airway Obstruction CAUSES

A 
Edema
Bleeding
Intraoral fractures
Nasal passage injury
Foreign body
55
Q

LeFort

A

Common fracture lines along the maxilla & face

56
Q

LeFort I

A

Horizontal fracture extending from nasal floor & hard palate through the nasal septum

57
Q

LeFort II

A

Triangular fracture from the nasal bridge, through the medial & inferior orbit wall, beneath the zygoma, & through the lateral maxilla wall

58
Q

LeFort III

A

Separates the midfacial skeleton from the cranial base, traversing the nasal root, ethmoid bone, eye orbits, & sphenopalatine fossa

59
Q

Trauma

Anesthetic Considerations

A 
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
Q

Radical Neck Dissection

A

Cancerous tumor resection from head & neck

Frequent comorbidities - elderly, smoker, ETOH abuse, CV disease, radiation therapy history

61
Q

Radical Neck Dissection

Preop Considerations

A 
Airway assessment
- CT results
- Consult surgeon
Tracheostomy or laryngectomy
Type & cross
62
Q

Radical Neck Dissection

Intraop Considerations

A 
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
Q

Radical Neck Dissection

Postop Considerations

A

Trach care
Controlled ventilation
CXR r/o pneumothorax
Monitor for laryngeal edema

ICU admission:

  • Edema & fluid shifts
  • Altered ventilation
  • Extensive anesthesia time
64
Q

ENT Key Points

A
  • 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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