ENT

Question 0

WHAT NERVE ARE YOU CONCERNED ABOUT DURING EAR SURGERY AND WHAT DO YOU DO ABOUT IT?

Answer 0

THE FACIAL NERVE. INTRAOPERATIVE BRAIN STEM AUDITORY EVOKED POTENTIALS ARE USED TO MONITOR ITS FUNCTION SO NO NMB IS USED….BUT STILL KEEP THEM VERY STILL.

Question 1

WHAT ARE MAIN CONSIDERATIONS FOR HEAD AND NECK SURGERY?

Answer 1

SHARED AIRWAY, AVOID SURGICAL FIELD, RESTRICT N2O AND NMB, USE OF LASER, HIGH PERCENTAGE OF PEDIATRIC PATIENTS.

Question 2

IF YOU CANT USE NMB DURING EAR SURGERY HOW DO YOU KEEP THEM STILL?

Answer 2

HIGH MAC ON VA AND NARCOTIC EVEN IF IT MEANS YOU HAVE TO PUT PERSON ON NEO GTT……THEY CANT MOVE!

Question 3

HOW DOES N2O AFFECT THE EAR?

Answer 3

N2O ENTERS THE MIDDLE EAR AND PARANASAL SINUSES MORE RAPIDLY THAN AIR CAN LEAVE WHICH INCREASES PRESSURE. IF THE EUSTACHIAN TUBES ARE IN PATHOLOGICAL STATE THEY WONT PASSIVELY VENT THE MIDDLE EAR. DONT USE N2O IF PT HAD PREVIOUS MIDDLE EAR RECONSTRUCTIVE SURGERY! DURING TYPANOPLASTY LIMIT N2O TO LESS THAN 50% AND D/C AT LEAST 15 MIN PRIOR TO CLOSE…..OR BETTER YET AVOID N2O ALTOGETHER.

Question 4

WHAT DOES MICROSURGERY OF THE EAR REQUIRE? (TYPE OF FIELD) AND HOW IS THIS ACCOMPLISHED?

Answer 4

A BLOODLESS FIELD. TILT HEAD 10-15 DEGREES TO DECREASE VENOUS BP AND THEREFORE DECREASE VENOUS BLEEDING PRESSURE. USE EPINEPHRINE FOR VASOCONSTRICTION, RELATIVE HYPOTENSION (SBP LESS THAN 90)

Question 5

WHAT ARE THE MAXIMUM DOSES OF EPINEPHRINE WITH VA?

Answer 5

SEVO 5 MCG/KG
DES 4.5 MCG/KG
ISO 6.7 MCG/KG

Question 6

AT WHAT PRESSURE DOES PASSIVE VENTING OF THE EAR OCCUR?

Answer 6

200-300 MM H2O

Question 7

WHAT IS THE SAFE INTRANASAL DOSE OF COCAINE?

Answer 7

1.5 MG/KG

Question 8

WHAT SYSTEMIC REACTION CAN YOU EXPECT TO SEE WHEN GIVING TOPICAL COCAINE INTRANASAL? AND WHAT CAN YOU DO ABOUT IT?

Answer 8

TACHYCARDIA, HTN, ARRYTHMIAS. FRONT LOAD PT WITH NARCOTIC TO ATTENUATE THESE EFFECTS.

Question 9

DURING A SEPTOPLASTY, WHAT IS IT IMPORTANT TO REMEMBER TO DO BEFORE TAKING OUT ETT?

Answer 9

TAKE OUT PHARYNGEAL PACK

Question 10

WHAT ARE SOME THINGS TO KEEP IN MIND FOR EXTUBATION OF SEPTOPLASTY?

Answer 10

SUCTION PHARYNX AND STOMACH….LOTS OF BLOOD. REMOVE THROAT PACK, CANT MASK THEM POST EXTUBATION, THEY NEED TO BE AN AWAKE EXTUBATION…..REFLEXIVE….PULLING FOR TUBE. THEY WILL HAVE VERY REACTIVE AIRWAY.

Question 11

WHAT ARE 4 GOALS OF ENDOSCOPY?

Answer 11

SUPPRESSION OF COUGH AND LARYNGEAL REFLEXES. RELAX THE MANDIBLE.
RAPID AWAKENING WITH RETURN OF PROTECTIVE AIRWAY REFLEXES.
ADEQUATE OXYGENATION DURING THE PROCEDURE.

Question 12

IF THERES ANY QUESTION ABOUT THE STATE OF THE PTS AIRWAY FOR ENT SURGERY HOW DO YOU DO A LARYNGOSCOPY?

Answer 12

DIRECT LARYNGOSCOPY OR FIBEROPTIC SHOULD BE PERFORMED AFTER LARNGEAL BLOCK IN THE AWAKE PT TO ASSESS DIFFICULTY OF INTUBATION.

Question 13

WHAT IS THE MALLINKRODT TUBE?

Answer 13

A SMALL (4,5) TUBE THAT IS AS LONG AS AN ADULT TUBE. GOOD FOR ENT SURGERY AS SMALL TUBE ALLOWS SURGEON TO VISUALIZE GLOTTIS, EPIGLOTTIS, ETC.

Question 14

IN WHAT 2 GROUPS OF PTS IS A VENTILATING BRONCHOSCOPE (SANDERS ) NOT WELL TOLERATED?

Answer 14

CHILDREN AND ADULTS WITH BULLOUS LUNG DISEASE. IE: BLEBS

Question 15

IS THE APNIC TECHNIQUE A VALID APPROACH TO LARYNX SURGERY?

Answer 15

YES

Question 16

WHAT IS A CONTRAINDICATION OF RIGID BRONCHOSCOPY?

Answer 16

CERVICAL SPINE PATHOLOGY AS THE NECK WILL BE HYPEREXTENDED.

Question 17

WHAT ARE THE ADVANTAGES OF LASER SURGERY FOR VOCAL CORD POLYPS?

Answer 17

IT PRECISELY CONTROLLES COAGULATION, INCISION OR VAPORIZATION OF TISSUES. MINIMAL EDEMA, RAPID HEALING.

Question 18

WHATS THE MAX AMOUNT OF O2 YOU CAN USE WITH LASER SURGERY?

Answer 18

30% O2. OXYGEN AND N2O ARE FLAMMABLE! CAN USE A MIXTURE OF HELIUM WHICH IS NON FLAMMABLE. OR ……HELIOX (HELIUM AND O2) WHICH ALLOWS YOU TO USE LOWER O2 AND ALLOWS LAMINAR FLOW.

Question 19

WHAT SAFTEY THINGS SHOULD YOU DO FOR A LASER SURGERY?

Answer 19

COVER PT AND YOUR OWN EYES WITH PROTECTIVE EYEWEAR. COVER ETT WITH SALINE SOAKED 4X4. USE SPECIAL LASER SHIELD ETT IMPREGNATED WITH SILICONE WHICH INCREASE THE TIME IT TAKES TO IGNITE ETT. OR A METAL TUBE. CUFF SHOULD BE INFLATED WITH STERILE SALINE-SOME MAY HAVE METHYLENE BLUE INSIDE. WRAPING THE ETT WITH METALLIC TAPE INCREASES THE MEAN TIME TO IGNITION. AVOID PAPER DRAPES, USE TOWELS. SURG. LUBE ON BEARD. HAVE A 60CC SYRINGE FILLED WITH WATER.

Question 20

HOW DO YOU TREAT AN AIRWAY FIRE?

Answer 20

STOP O2. REMOVE THE BURNING TUBE. REINTUBATE…..USE A TUBE EXCHANGER IF A DIFFICULT INTUBATION. FLUSH PHARYNX WITH COLD SALINE. THEY WILL DO A RIGID BRONCH TO ASSESS THE DAMAGE AND PULL OUT DEBRIS. GIVE HUMIDIFIED O2, STEROIDS, ANTIBIOTICS, AND CONTROLLED VENTILATION….POSSIBLE TRACH.

Question 21

WHAT IS AN ANODE TUBE?

Answer 21

ETT WITH WIRE REINFORCEMENT….A GOOD CHOICE FOR RADICAL NECK SURGERY.

Question 22

IF YOUR RADICAL NECK PT HAS CAD (AS THEY OFTEN DO) WHAT ARE SOME THINGS TO THINK ABOUT FOR INDUCTION?

Answer 22

DECREASE THE INDUCTION AGENT…. DONT WANT THEM TO GET HYPOTENSIVE, TACHY, OR INFARCT. TO PRESERVE BP CONSIDER ETOMIDATE OR CUT THE PROPOFOL DOSE WITH NARCOTIC UP FRONT. DECREASE INHALATION VA ALSO.

Question 23

WHAT WOULD YOU CONSIDER FOR INDUCTION OF PT WITH CHF?

Answer 23

THEY HAVE POOR LEFT VENT FUNCTION. DONT USE PROPOFOL…..USE NARCOTIC AND ETOMIDATE.

Question 24

WHAT HAPPENS WHEN THE CAROTID SINUS IS MANIPULATED DURING RADICAL NECK SURGERY?

Answer 24

YOU CAN SEE BRADYCARDIA, HYPOTENSION, OR CARDIAC ARREST.

Question 25

CAN YOU USE A NMB FOR PAROTIDECTOMY?

Answer 25

NO CUT IS IN FRONT OF THE EAR AND THEY WILL NEED TO MONITOR FACIAL NERVE FUNCTION WITH AUDITORY EVOKED POTENTIALS.

Question 26

WHAT ARE THE GOALS OF ANESTHESIA FOR TONSILLECTOMY/ UPPP?

Answer 26

KEEP PT DEEP (GA) TO PREVENT REFLEX INDUCED HTN, TACHYCARDIA OR ARRYTHMIA. THEY ARE HIGH RISK FOR PONV AND A REACTIVE AIRWAY.

Question 27

WILL THE SURGERY BE POSTPONED FOR RECENT UPPER RESPIRATORY INFECTION SUCH AS A COLD OR BRONCHITIS FOR A TONSILLECTOMY /UPPP?

Answer 27

YES! INCREASES AIRWAY IRRITABILITY.

Question 28

WHAT TYPE OF CLEARANCE DOES A DOWN SYNDROME PT REQUIRE BEFORE TONSILLECTOMY?

Answer 28

C SPINE CLEARANCE. THEY HAVE WEAK NECKS AND IT WILL NEED TO BE HYPEREXTENDED.

Question 29

WHAT IS THE HYDRATION REQUIREMENT FOR TONSILLECTOMY AND WHY IS IT SO IMPORTANT?

Answer 29

3/5ML/KG. BLOOD LOSS IS DIFFICULT TO ESTIMATE.

Question 30

WHAT IS THE TONSIL POSITION FOR EMERGENCE AND WHY USE IT?

Answer 30

SIMS POSITION….PT ON SIDE WITH HEAD SLIGHTLY DOWN. THIS PREVENTS SECRETIONS FROM DRIPPING DOWN ONTO THE VOCAL CORDS. USE THIS POSITION FOR TONSILLECTOMY EMERGENCE.

Question 31

IN WHAT POSITION DO YOU EMERGE A UPPP PT?

Answer 31

HIGH FOWLERS.

Question 32

FOR A PEDS TONSILLECTOMY WHAT SHOULD YOU HAVE EN ROUTE TO PACU AND WHY?

Answer 32

4 MG/KG SUX
20 MCG/KG ATROPINE
HAVE IM NEEDLES ALSO.
THESE ARE YOUR RESCUE MEDS TO BREAK A SPASM. THEY ARE HIGH INCIDENCE OF LARYNOGOSPASM DUE TO BLOOD SECRETIONS AND INCREASED STIMULATION.

Question 33

WHAT IS A COMPLICATION OF A TONSILLECTOMY?

Answer 33

REBLEEDING. OCCURS 3-6HRS POST OP USUALLY BUT CAN OCCUR UP TO 6 DAYS.
MUST TREAT AS FULL STOMACH FOR SWALLOWING BLOOD….RSI. HYDRATE WELL. MAKE SURE TO DO AN AWAKE EXTUBATION!

Question 34

WHAT ARE 2 THINGS YOU NEED TO SEE BEFORE PULLING ETT FOR TRACH INSERTION?

Answer 34

FEEL VENTILATION VIA BAG/HEAR BREATH SOUNDS AND SEE ET CO2.