ENT Flashcards
What are some general challenges of ENT
- shared Airway
- increased risk for fire
- restricted use of N2O and MR
- pediatric population
- PONV (especially the inner ear & blood going into stomach)
What consist of the Middle ear
- tampanic membrane (ear drum): separates inner form outer ear
- Malleus/Hammer
- Incus:
- Stapes
What is the major nerve transversing the inner ear cavity?
Facial Nerve #7
what is Tympanoplasty
repair/reconstructive surgery of the tympanic membrane/ear drum due to chronic infection or trauma.
• May take a graft from tissue under the skin around the ear and use to reconstruct the ear drum itself
What two ways can you do a Tympanoplasty
- Transcanal – done through the ear canal.
* Post Auricular – via an incision behind the ear
What is the common graft site for a Tympanoplasty
the tragus
What is a stapedectomy? And what are some possible causes?
removal of the innermost bone (stapes) due to:
- otosclerosis (abnormality of bone formation over the stapes hindering the movement )
- injury
- -congenital malformation
Generally these patients are HOH
What is a Mastoidectomy and what are some possible causes?
removal of a portion of the mastoid bone due to
a. mastoiditis – infection of the mastoid bone
b. choleasteatoma – disease state where the squamous epithelium grows within the middle ear or skin, can cause major damage to the vital structures, invade the dura, facial nerve, and the semicircular canal. If not treated it is potentially lethal.
c. insertion of cochlear implant
d. surgical approach for acoustic neuromas and facial nerve tumor
How are Mastoidectomies approached?
the Post Auricular Approach
What is a simple Mastoidectomies
gain access to the mastoid itself, use a drill and bur away the diseased mastoid air cells that are effected
- -exposing the facial nerve and the semicircular canals and the middle ear space.
- -Then they close and apply a dressing.
What is a modified Mastoidectomies
is similar to simple except that the posterior wall of the external auditory canal is removed so the mastoid can be visualized through the external canal during post op visits
What is a radical Mastoidectomies
includes not only removal of the posterior external canal but also includes removal of the tympanic membrane, malleus and incus, leaving the stapes there.
What are some anesthesia considerations for Middle ear surgeries?
Positioning- 90-180°
head rotated laterally– This will cause the ETT to move when they turn the head. **LISTEN TO BS
long circuit
-avoid extreme tension of the sternocleidomastoid
= potential to pull the muscle, and C1, C2 subluxation with older patients and they are at risk for atlanto-axial subluxation
Nerve preservation – The facial nerve is the main nerve in the middle ear. The surgeon will ID it and preserve it during surgery.
NO nitrous - diffuses into air containing cavities causing graft displacement.
—-Normally, pressure in the inner ear is vented by the Eustachian tube into the nasopharynx
Control bleeding-mild HOB↑ 30°
High risk for postoperative N/V- prophylactic anti-emetics
Avoid coughing/bucking with emergence=bleeding
IF you MUST use nitrous for a middle ear surgery what percentage should you use?
limit N2O to 50% and D/C 15 minutes prior to graft placement
How do we do Control bleeding?
systolic around 90
propofol gtt in combination with inhalation anesthetics
the surgeon can inject epinephrine to decrease bleeding in the field
(Any minute drop of blood can obliterate the surgeons view)
How can we facilitate a smooth emergence for an ENT procedure?
(avoid straining, bucking, retching)
- deep extubation to prevent the coughing and bucking
- Lidocaine 1-1.5mg/k IV 60-90 sec. prior to extubation – to blunt those responses.
What are some indications for Myringotomy and Tympanostomy tubes
Indication: Chronic otitis media or infection of the inner ear resulting in fluid accumulation in the middle ear, which causes increased pressure and eventually hearing loss.
What are some anesthesia considerations for Myringotomy and Tympanostomy tubes
- most done in peds
- short procedure
- do NOT pre-medicate these patients
- it is NORMAL to have a URI (dont cancel SX)
- drifted to sleep with a mask induction
- *nitrous is ok due to the tube
- O2 post-op
What is a Rhinoplasty?
reconstruction of the external nose
Can be functional or cosmetic.
What is a septoplasty?
straightening of the deviated septum
can have air flow obstruction of the effected side, leading to poor sinus drainage and sinusitis
What is a Turbinoplasty/Turbinectomy
reducing the size of the turbinates by trimming them or total removal of the turbinates.
What is the largest turbinate??
what are the three turninates
Largest -inferior
inferior, middle and superior.
What are some anesthetic considerations for nasal surgery?
- table turned
- head up 30 (decrease bleeding)
- Cocaine 4% pledgettes
- Lido 1% with epi 1:100k injected
- GA with ETT or RAE-
- hypotensive technique
- Remove their throat packing
- suction their oropharynx
- SMOOTH emergence: no pressure on their nose
What is something we are always watching for when the surgeon injects lidocaine with epi?
Intra-vascular injection – extreme tachy and HTN
In the pre-op area, what something to remind your patients of about when they wake up
They wont be able to breath through their nose after surgery
Where should you secure the tube for a nasal surgery?
on the mandible….. not the maxilla
What do all sinuses need to prevent infection?
ventilation
Ventilation to the sinuses is primarly provided through what?
osteomeatal complex
found under then the middle turboniate
This area is very small so any abnormality will result in a problem
Name the four sinuses and where they are
1) maxillary sinus: located under the eyes.
2) frontal sinus: superior to the eyes in the frontal bone
3) ethoidal located between the nose and eyes (tiny)
4) splenoid sinus: located in the splenoid bone, located at the center of the skull base
What important structure is close to the splenoid sinus?
pituitary
What is the largest sinus?
Maxillary sinus
What are the approaches for sinus surgery?
- Endoscopic-endoscope through the nostrils (preferred)
2. External-through the skin or oral cavity (sublabial, medial orbital or coronal)
What are some anesthesia considerations for sinus surgery?
- Since these patient will have chronic rhinosistis they generally have hyper-reactive airways.
- bed turned 180 degrees, head elevated, and the arms tucked.
- Controlling of bleeding. 4% cocaine pack jets inject their local with epi
- hypotensive technique
- Make sure the eyes are lubricated and closed
- The surgery will be done under GA with an ETT.
- The close proximately of the brain, so we want them to be really deep, or use muscle relaxants.
- Emergence needs to be smooth and non-bucking
- Remove oral packs
- Drop an OG to suction out any blood or debride or blood that may have gone down into the oral pharyx
- Give anti-medics
What are some surgical complications of sinus surgery?
- Corneal Abrasions
- Vision loss -damage to optic nerve or hematoma
- damage to lacrimal ducts
- puncture of the dura causing cerebral spinal fluid leak
- carotid artery injury (the paranasal sinuses are close )
- VAE (head higher than heart)
- Brain Injury (especially with tumor removal)
What are the palatine tonsils and adenoids made of?
lymph tissue
What are some indications for a tonsillectomy?
- Recurrent tonsillitis; strepacolcis type A
- Para-tonsil abscesses
- Obstructive sleep apnea;
What are some anesthesia considerations for a tonsillectomy?
• URI
• Check for loose teeth
• Consider anti sialagogue
• Usually pediatrics
• Position-supine with neck extended
• Mouth gag- (keep them DEEP)
• GA ETT-deep plane of anesthesia
• Removal of throat pack
• PONV-OG/Anti-emetics/corticosteroids
(if you drop an OG be gentle)
• Extubate awake
• Transport positon-“tonsil position” pediatrics/ adults semi fowler’sWhat surgery do you not secure the tube?
tonsilectomy
What do we need to know about MR with a tonsillectomy surgery?
USE a short acting because the surgery will only take 20-30 min.
