ENT Flashcards

Question

What is the oculocardiac reflex?

Answer 1

**Aka Trigeminal-vagal reflex** * Reflex triggered: * → pressure on globe, pain, and / or traction on extraocular muscles, retrobulbar block, orbital injections, trauma, and hypoventilation (hypercarbia and hypoxemia) * Ex: \*traction on medial rectus muscle * Pressure on periosteum * **Afferent limb** arises from ophthalmic division of trigeminal nerve → goes to gasserian ganglion and sensory nucleus of trigeminal nerve near the 4^th ventricle * **Afferent limb** synapses with motor nucleus of vagus nerve → **efferent impulse** that travels to heart (via vagus nerve) → leads to: * Decreases HR * Decrease contractility

Answer 2

* Bradycardia * atrioventricular block * ventricular ectopy * negative inotropy * asystole * Occurs most often during strabismus surgery (peds pts) * Pulling/traction of medial rectus muscle * May be seen more often under topical anesthesia

Answer 3

* Maintain normal ETCO2, SpO2 * Pretreat with anticholinergic * (atropine or glycopyrrolate)→ have ready * Considerations: * \*Pts typically elderly (increasing HR decreases coronary perfusion pressures)

Answer 4

* **Stop stimulus** * Assess ventilation: * Correct hypoxia/hypercapnia (can worsen reflex) * Admin: 100% FiO2 * normal ETCO2? SpO2? * Deepen patient * Atropine 7 *u*g/kg increments or Glycopyrolate * Worsen → Epi * Local anesthetic (lidocaine) into muscle

Answer 5

* High risk population/low risk surgery * Elderly, co-morbidities * These Pts cannot typically have outpt sx: * Severe cardiomyopathy, pulmHTN * Home O2 * Super morbid obese * Known DAW * OK to do just 1 mg Midaz * Chronic conditions that may make it difficult to lie still and /or supine * SOB, chronic cough, nasal drip, reflux, nausea * Parkinson's, Alzheimer's or claustrophobia, mentally disabled, back pain, OSA * Pediatric patient cooperation * Non-english speaking, deaf * Might have to consider more than MAC case * *EKG not indicated per AHA/ACC* * NEED to educate pt on what to expect. pt needs to stay still, will have blue drape over face * 30% of eye injury during ophthalmic surgery with anesthesia were related to patients moving. * Blindness was the outcome in all cases! * Most problems occurred under GA, 25% under MAC. * \*\*Ensuring pt immobility during the procedure are therefore of the utmost importance

Answer 6

* Pre-operative ophthalmic drops * Continue home medication regimens * Education of being awake/still during surgery (what to expect) * Blue drape over face * Wont be able to see * Duration * Avoid over-hydration * Control HTN * Control BS * No steroid coverage needed * Dry secretions * Sniffing/coughing → causes movement * Treat reflux * Good intraoperative positioning * **Preop:** * Preexisting anticoagulants * weigh risks vs benefits (talk to surgeon) * *don't have to stop anticoag necessarily* * ASA Recommendations: * ASA 1 or 2: No routine preop lab testing before cataracts sx * EKG done based on pt hx * *considered low risk sx*

Answer 7

* \*Regional Anesthesia * \*Topical Anesthesia * Sedation * Adjunct w/ topical * General Anesthesia **Goals**: * safety, akinesia (immobility of eye), analgesia * minimal bleeding * avoidance or obtundation of the oculocardiac reflex * prevention of increased IOP * awareness of drug interactions (drops) * smooth emergence devoid of vomiting, coughing, or retching.

Answer 8

* Retract the eye lid and insert the needle (3-cm, 23-25 gauge blunt needle) thru temporal aspect of lower lid (below the globe) * direct needle perpendicular (bevel up) to the plane of face toward the orbital apex with sufficient depth and angulations that the cone is penetrated. * At junction of inferior and lateral walls of orbit * Inferior to orbital rim * **Aspirate.** LA instilled posterior to the eye. * Usually equal amounts of lidocaine 2% and bupivicaine 0.75% without epinephrine (@ 2-3 ml). * Hyaluronidase is added to speed tissue penetration. Place gentle pressure on the eye for about 5 minutes to increase spread of LA (or use Honan cuff compression balloon). * Onset around 5-10 minutes * → see “down gaze”

Answer 9

* Routine monitoring * Position: * Supine * HOB 10-15 degrees up * Oxygen by nasal cannula * Sedation * Propofol in small increments (20mg) but no analgesia, pt may startle upon needle insertion * Remifentanil (0.3-0.5ug/kg) lasts 2-5 minutes while the block is going in. * Caution w/ Midazolam, can be added depending on pt age. * Infusions are NOT necessary; you want the pt to remain aware and unobtunded during surgical procedure * LA instilled by injection posterior to eye directly into the orbital cone * 2% lidocaine/0.75% bupivicaine 1:1 ratio, 2-3 ml * Hyaluronidase added for tissue penetration * Excellent akinesia and analgesia

Answer 10

* **Retrobulbar hemorrhage** **- *most common\* - ~1% cases*** * Venous hemorrhage – not as bad * Arterial hemorrhage → swelling, proptosis (eye bulge out), immobility of globe * Compressive hematoma → vision loss! * Intraarterial injection → Seizures! * LA pass from ophthalmic a. to internal carotid → thalamus and midbranch structures * ASPIRATE * Globe perforation * Optic nerve damage * OCR * Seizures * Resp arrest * **Partial/total brainstem anesthesia * Aphagia * Confusion * Apnea * CV arrest * Szs * Supportive tx → resolve in few hrs**

Answer 11

* 23 G blunt needle inserted thru skin and advanced along the orbit floor directed parallel to the globe (thru the lower lid) toward the sphenoid bone. * “Needle introduced outside cone” → * **NO risk of retrobulbar hem** * Decrease risk of **optic N injury** * LA instilled into extraconal space (outside the muscle cone) and will slowly penetrate toward the optic nerve. * Two separate injections: * 1. Inferior/Temporal * 2. Superior/Nasal

Answer 12

* Safer * C/t retrobulbar block bc muscle cone not penetrated (into extraconal space) * Slower onset of action * 10 min vs 5 min * Higher volumes of LA * Ex: 5- 10 ml (c/t 2-3 ml) * Lower incidence of **complete eye akinesia** * **Complications:** * Globe perforation * Failure of block

Answer 13

* Anesthetic drops applied * Using blunt cannula → * LA injected (1-3 ml) under Tenon’s fascia * Uses: * Excellent analgesia for iris & anterior eye * **Complications:** * conjunctival edema * Technique: * topical drops applied to anesthetize surface * speculum is placed to retract lids → have pt look out and up → take iris scissors to “nick” in conjunctiva/ or use cautery while a curved blunt ophthalmic needle (cannula) is directed toward outer edge of globe into a Bare Sclera * Bare sclera: a potential space under Tenon’s fascia posteriorly * Needle is inserted 1.7 cm depth [1-3cc can be inserted depending on size of globe]. * Then LA in injected into space.

Answer 14

* Anesthesia to eyelids * Keeps orbicularis muscle still * Ex: prevent increases in IOP from squeezing lid * **Complications:** * facial droop * vocal cord paralysis * respiratory distress * **Block technique: l**ocal infiltration field block CNVII as it exits stylomastoid foramen or at level of orbicularis oculi muscle or at condyle of the mandible.

Answer 15

* Instillation of LA solution onto eye * Ex: Proparacaine, Tetracaine, Lidocaine * Anesthetized locations: (2) * Cornea * Conjunctiva * Ex: if req total akinesia of eye → topical wont be ok * Considerations: * Hyaluronidase adjunct * Speeds up tissue penetration * Sedation +/- * Want cooperative but still patient * **Disadvantage**: * potential eye movement * increased patient anxiety * discomfort

Answer 16

* **Technique:** * All standard monitors on * Supplemental oxygen by NC * **Blend w/ air if using cautery** * Positioned for comfort * Meds: Mild/Mod sedation * Propofol bolus @ 0.5 mg/kg for block placement only * Midazolam 0.5-1 mg and/or Fentanyl 12.5-50 *mc*g * Ex: cataract sx- just topical LA needed * Avoid CO2 build-up under drapes * *also avoid O2 buildup- use suction* * Additional info: * 60-70% ophthalmic sx: combo of block & MAC * MAC: * Less hypotension * Faster recovery * Less PONV *Other drug options* * *Precedex, slower onset, nut used normally* * *Ketamine causes too much dysphoria, esp in elderly* * *Just need propofol when giving the actual block*

Answer 17

* Smooth intubation * LMA ok * Avoid: meds increasing IOP * Ketamine * succinylcholine * Blunt responses to airway maneuvers/avoid pressure on eye * Avoid N2O * Ex: bc injection of gases (sulfahexafluride, octofluropropane) to cause retinal tamponade * Avoid N2O use for 3-8 wks

Answer 18

* **Avoid:** * Hypoventilation/ may want mild hyperventilation * Ex: acidosis → increases IOP * HTN (treat) * bucking or moving * direct pressure on eye * *Typically not a very stimulating procedure once eye topicalized, may need lower anesthetic during case.*

Answer 19

* **Emergence** * Smooth wake up * Prevent coughing, bucking, vomiting * Ex: Propofol, IV lidocaine, deep extubation * **Pretreat w/ antiemetics** * **Post-operative** * Treat PONV * 2fold- some risky for increase N/V (like strabismus sx) and increase IOP * Good pain control **Goals**: smooth induction, stable IOP, avoid OCR, motionless field, smooth emergence, NO N/V, No postop pain * 30% cases req GA * Peds * Adults w/ cog impariement * Watch fluids

Answer 20

* Sclerosis of trabecular tissue → causing increase IOP → affecting vision * develops slowly and bilaterally * **-Treatment:--- *frequently just treated by meds, more chronic process*** * Miosis * decrease production of aqueous humor * trabecular stretching

Answer 21

* Peripheral iris moves into direct contact with corneal → mechanically obstructing aqueous flow * acute process, more rare * **Treatment:** * Immediate surgery * *Glaucoma is characterized by an increase in IOP to the point where blood flow is compromised (diminished capillary blood flow to the optic nerve) and the optic disc is compressed, which will eventually lead to blindness* * Avoid elevation in IOP

Answer 22

* Surgeries performed: * Laser trabeculoplasty * Trabeculectomy * Tube-shunt surgery * **Anesthetic Management** * Continue medical management to maintain miosis * Limit the use of anticholinergics (cause dilation) * Avoid increases in IOP * If severe acute glaucoma attack- dry pale painful eye: * treat w/ Mannitol or Acetazolamide

Answer 23

* Defined: opacification of the crystalline lens * Leading cause of treatable blindness * Surgery * **ICCE** w/ IOL * Open cataract extraction ICCE—intracapsular removal of cataract thru large incision * **IOL** –intraocular lens implant--once ECCE and phacoemulsification done. Place within nucleus again. * ECCE w/ IOL * **ECCE** –extracapsular cataract extraction ; removal of crystalline lens via opening anterior lens capsule (capsuletomy) and phacoemulsification then ‘cleans’ nucleus with ultrasound to fragment and remove crystallized lens debris. * **IOL** –intraocular lens implant--once ECCE and phacoemulsification done. Place within nucleus again. **Anesthetic Management** * Topical block with minimal sedation or regional block * Supplement w/ Midaz

Answer 24

* Defined: * separation of retina from its attachments to its underlying tissue w/in eye. * Result of: * Retinal break, hole, or tear * Surgical treatments: * scleral buckle * vitrectomy * pneumatic retinopexy (injection of gas) * cryotherapy * A retinal detachment is a medical emergency

Answer 25

* Pneumatic retinopexy: * repair retina, then use insoluble or poorly diffusible gas to tamponade retinal break against the wall of the globe * ***Caution when using N2O*** * Sulfur hexafluoride (SF3) * No N2O for 10 days post-injection * Perfluoropropane (C3F8) * No N2O for 30 days post-injection * Air * No N2O for 5 days post-injection

Answer 26

* Concerned w/ open eye injury VS. full stomach * Concerns: Balance b/t * aspiration risk * blindness risk (from increased IOP or extrusion of ocular contents) * **Contraindicated:** * **Ophthalmic blocks** * Technique: * RSI (d/t risk of full stomach) * Succs- ok * (risk of lost AW\>\> small increased IOP) * DL increases IOP a lot → RSI quickens intubation and theoretically decreases IOP (*rsi also decreases risk for hypoxia/hypercarbia which also increases IOP)* * Roc- 1.2 mg/kg for RSI ok * Need to limit increased IOP * Succs admin w/ propofol helps * Need motionless surgical field

Answer 27

* Most common pediatric ophthalmic surgery * Misalignment of visual axis w/: * Amblyopia * Diplopia * loss of stereopsis

Answer 28

* Generally a **myopathy of extraocular muscles** * **→ risk of pt having myopathy!** * LMA (peds pop) * Risk increased: * MH * PONV * OCR- *oculocardiac reflex* * from direct muscle manipulation/traction * ex: tell surgeon/remove stimulous * bradycardia persists → admin glyco or atropine * Oculorespiratory reflex → respiratory pauses * Afferent limb same as OCR * Efferent limb *don't know what efferent limb is* * Not responsive to anticholinergics * Not typically problem bc already assisting vent (LMA)

Answer 29

* **Corneal Abrasions** * Lubricate, tape, watch for pt’s rubbing eyes * **Blindness- post op vision loss** * **Chemical Injury** * **Thermal Injury** * **Hemorrhagic Retinopathy** * **Retinal Ischemia** * **Acute Glaucoma Attack**

Answer 30

Surgeries: * Cardiac * Neuro/spine * Head and neck **Causes: KNOW** * **Ischemic optic neuropathy** * Anterior or Posterior ION * Most common insult: risk higher w/ → * Large BL * \> 6 hr sx * Prone sx- venous congestion * **Central retinal artery occlusion** * Occurs at **optic disc** → permanent blindness * d/t increased IOP d/t external pressure during positioning * painless vision loss/decreased acuity * prognosis for recovery of vision is pretty poor * **Cortical vision loss** **Avoid**: * getting chlorhexidine in eyes (chem burn) * avoid warm items

Answer 31

**General Principles of ENT Anesthesia** * Airway safety * The provision of a clear, free, and unobstructed airway is the principal concern for all ENT procedures * Factors affecting airway safety: * Patient factors * Remote surgery * Surgical factors * Shared airway **General Principles of ENT Anesthesia** 1. Simple 2. Provide complete control of AW w/ no aspiration risk 3. Control ventilation w/ adequate oxygenation and CO2 removal 4. Provide smooth induction and maintenance of anesthesia 5. Provide a clear, motionless surgical field 6. Free of secretions 7. Not impose time restrictions on the surgeon 8. Not be associated with any risk of airway fire or CV instability 9. Allow safe emergence with no coughing, bucking, breath holding, laryngospasm 10. Produce a pain-free, comfortable, alert patient at the end

Answer 32

* Good AW assessment- *high risk CICV situation* * Size/Mobility/location of lesion(s) * OSA ? * Eval CT scan, conversate w/ ENT surgeon * *ENT surgeon usually has already done preop endoscopic exam in office and will know what airway will looks like* * **Evaluate**: * Stridor * implies airway diameter \< 4-5mm * Hoarseness * Voice change * Difficulty laying flat

Answer 33

* Table position in OR * Need extra length to circuits and IV tubing * Muscle relaxation or no? * Monitor Nerve fx → be aware of type of case * Pre-Medications: * **Anticholinergics:** * Reduces vagal tone * reduces secretions * increases bronchodilation * **Corticosteroids**: ~8-12 mg * Decrease edema formation * reduce N&V * prolong LA analgesic effects * \*PONV: * Blood/sx in stomach * Decompress belly * Throat pack- minimizes runoff * Make sure to take out * Antiemetics * **Deliberate controlled hypotension** * MAP 60-70 mmHg * A-line * Drugs: ex BB

Answer 34

* Head up position * Decreases edema * Observe for bleeding, edema * Administer humidified oxygen → decreases swelling * Watch for pneumothorax * Watch for respiratory failure * Stridor: Tx of laryngeal edema * Steroid- prolonged onset * Racemic epi mist\*

Answer 35

* **Closed system-** w/ cuffed ETT * **Open system-** **sharing AW w/ surgeon** * Spontaneous ventilation and insufflation techniques * Muscle paralysis and jet ventilation

Answer 36

* **Advantage**: * Routine technique * Protection of lower airway * Control of airway * Control of ventilation * Minimal pollution by VA * **Disadvantages**: * **Surgical access and visibility limited** * Small **ETT →** High ventilation pressures needed * VC damage w/ intubation * Esp if lesions on VC * Risk of laser airway fire

Answer 37

Small ETT * Microlaryngoscopy tubes (MLT) * 4-5mm * Long, small tubes w/ * high-volume/low-pressure cuffs * Laser tubes * Metal tube (only fire-resistant tube) * NO cuff * Or double-cuffed * Colored saline in cuff (if perforated by laser → see blue in field) * Closed system is Beneficial: * Prevent extubation, disconnects, and leaks * Assess ventilation continually * Observe chest movement, auscultation, pulse oximetry, ETCO2, blood gas analysis * Orchestrate turning

Answer 38

* **Advantages**: * Laser safety * Wont be ventilating when laser used * Reduced risk of ETT-related trauma * Complete laryngeal visualization\* by surgeon * **Disadvantages**: * Unprotected lower airway * Lack of control of ventilation * Operating room pollution w/ VA * Specialized knowledge, equipment, experience required * Know how to use JET

Answer 39

* SV and Insufflation technique * Spontaneously breathing patient with natural airway * Insufflation of anesthetic gases via * A small catheter in nasopharynx and above laryngeal opening → giving O2 and VA * Tracheal tube cut short and placed in nasopharynx emerging just beyond soft palate * Nasopharyngeal airway * Side-arm channel of laryngoscope or bronchoscope

Answer 40

* Subglottic jet ventilation by: * Jetting needle attached to a laryngoscope or bronchoscope * Transtracheal catheter thru cricothyroid membrane * ETT: Small-diameter (2-3 mm), cuffed/uncuffed, specifically designed for jet ventilation * Provides high-frequency (\>1 Hz, 60 breaths/min) w/ ventilator rates 100-150/min * Automated high-frequency ventilators with alarms and automatic interruption if pressure limits reached Hand-triggered devices- usually low-frequency jet ventilation (8-10 breaths per min) to allow adequate time for exhalation via passive recoil of lung and chest wall and prevents air-trapping and build-up of pressure in small airways; Ventilate at low pressures of 30-50psi. [least amount possible] Inspiration is 1.5secs, expiration 6secs High-frequency jet ventilators (oscillatory ventilation) jets gas at 1-10 Hz; both inspiration and expiration are active; driving pressure, frequency, inspiratory time, and composition of jet gas can be adjusted

Answer 41

* Preoxygenation * IV induction * NDMR\* (paralyzed/apneic patient) * Laryngoscopy * Topical LA * LMA or ETT inserted * **Ventilation w/ 100% oxygen until surgeon ready to site the rigid laryngoscope with jetting needle** * Anesthesia maintained with propofol infusion + remifentanil infusion * *TIVA typically better* * At the end of surgery, LMA reinserted * NDMR antagonized (reversed) * Anesthetic infusions stopped * Smooth awakening and LMA/ ETT removal

Answer 42

Adequacy of jet ventilation assessed continuously by: * Observation of chest movements * Oxygen saturation readings * Listening for changes to the sound during air entrainment and exhalation * Observation of airway patency **Complications of jet ventilation:** * Crepitus * Pneumothorax * Barotrauma * Gastric distension Contraindicated in * children [have a higher incidence of pneumothorax/SQ air], * obese pts, and * pts with bullous emphysema

Answer 43

* Laser light beams are primarily used for thermal effects * CUT * COAGULATE * VAPORIZE tissues * Lasers have one wavelength: * moving in the same direction * beam is parallel * emit small amount of radiation * Advantages: * very precise * minimal edema * minimal bleeding * Most common: CO2 laser common in Airway * d/t shallow depth of burn and extreme precision * Long wavelength absorbed by surface tissues

Answer 44

* **Atmospheric contamination** * Plume of smoke and fine particulates- *wear special mask* * Deposition in lungs * Leads to: * Pneumonia * Inflammation * viral infections * wear special mask * **Vessel/structure Perforation** * **Embolism** * **Inappropriate energy transfer** * **Reflection/Scatter** of beams → cause immediate/delayed injury to normal tissue (esp eyes) * CO2-reacts at surface → corneal damage * Nd: YAG/argon-pass thru the cornea to the retina * **\*TAPE PT EYES CLOSED AND COVER W/ WET GAUZE** * **\*PROTECT YOUR OWN EYES**

Answer 45

Fire- lasers produce intense heat * CO2 laser penetrate ETT → ignite fire * O2 & N2O support fires * Usually the subglottic, epiglottic and oropharyngeal areas are involved * Inhalation of smoke can cause: * bronchospasm * chemical injury * → resp. failure * **Strategies to reduce AW fire:** * Reduce flammability of ETT 1. Double cuff 2. Metal tube * Remove flammable materials from AW by using jet ventilation or intermittent extubation with or without apnea * Reduce available oxygen 1. \< 0.30 FiO2 * **Avoid:** 1. paper drapes 2. oil-based lubricants 3. caution with alcohol-prep solutions 4. O2 accumulation under drapes

Answer 46

* Surgical visibility vs airway control * GETA with laser ETT and methylene blue or NS in the cuff\<*-- most control over airway* * Insufflation techniques thru nasal tube * “open” technique – NPA * Jet ventilation thru jetting arm of scope * Apneic technique- intubate/extubate pt * \*Lowest possible FiO2 * \*Protect eyes with laser safety eyewear or saline-moistened pads and laser eye shields * \*Face and neck should have wet gauze over them * \*Have NS readily available to douse fire

Answer 47

* Remove burning ETT and/or other material from airway * Stop ventilation/turn of flows * **D/C O2** * Flush pharynx w/ cold **SALINE** * Mask with 100% O2 * When fire is out * Laryngoscopy and bronchoscopy to assess damage * Administer: * humidified gas * steroids * antibiotics * May need to reintubate, or even trach, and control ventilation * Check ABGs, SpO2, CXray, etc

Answer 48

* GETA or jet-ventilation * Technique: * ETT 8.0 or larger- *to allow bronchoscope to pass* * **may use LMA with bars broken * Ensure immobility * Possible antisialagogue * TIVA has advantages over VA (pollution) * Short-acting drugs * Adjust venti rates w/ manipulation of scope

Answer 49

* Adenoids: * Massive lymphoid tissue posterior to nasal cavity * Become hyperplastic → see obstruction/congestion * Take tonsils & adenoids * Indications: * severe infection of tonsils * hypertrophy of tonsillar bed * Associated with: * OSA – LT complications → * \*Cor pulmonale, PHTN, RV hypertrophy * URIs * Increase virulence post op * Increase risk laryngospasm/bronchospasm

Answer 50

* Evaluate loose teeth (age 4-7) * ? Recent URI * ? Recent antibiotic use * OSA * Assess AW – DAW? → Awake FOB\*\* * Peritonsillar abscess * Dental Abscess * → Lead to Trismus (lockjaw) → impairs mouth opening\*

Answer 51

* **Induction** * Possible stridor or obstruction – hyperplastic tonsils * GA- ETT or LMA? * Oral RAE or reinforced ETT (surgeon uses a mouth gag) * Tape midline → less likely to kink w/ retractors * **Maintenance** * Supine with table turned 45 degrees * Deep anesthetic level- don’t want coughing * Hydrate well → poor PO intake postop * Short-acting narcotics * Esp if suspecting OSA

Answer 52

AIRWAY, AIRWAY * **SMOOTH EXTUBATION** * **High incidence:** * **Laryngospasm** * **stridor** * **Admin: Lidocaine/precedex** * Throat pack out * Sx/decompress belly * Position on extubation: * Side-lying with head slightly down * PONV prophylaxis * Pain control: * Tylenol * Steroids (for edema/pain)

Answer 53

* Occurrence: * Acutely: \< 6 hrs postop * 7-10 days postop * Determine the extent of blood loss * Check: * Hbg/Hct * Coags * T&C * Hydrate well * No premedication * **CAUTION:** * hypovolemia * Full stomach (RSI→ swallowing blood) * airway obstruction * Potential DAW * RSI w/ **head down (prevent aspiration of blood)** * Place NG Tube * extubate AWAKE

Answer 54

* Leading cause of accidental deaths in pediatric patients \< 1 yo * DO NOT want to dislodge foreign body/push distally into AW * **Technique**: * Don’t upset child → screaming full obstructs AW * Have parents there for induction * No premeds * Sitting position * **Induction:** * Gentle mask inhalational induction * Maintain SV * no cricoid/no positive pressure ventilation * Surgeon should be prepared to perform tracheostomy or cricothyrotomy * **Medications:** * Anticholinergics * dry secretions * prevent bradycardia * Racemic epi (postop) * Reduce swelling * Dexamethasone, antibiotics, O2 postop

Answer 55

* Acute infection of supraglottic structures (epiglottis, arytenoids, epiglottic folds) * **Presentation**: * rapid, * sudden sore throat * fever * dysphagia * drooling * open mouth * stridor * respiratory distress * tripod position * **Population**: (differentiate from Croup) * 2-6 yo * H-Flu * Can see in adults, but larger diameter of AW (medically managed) * Awake FOB intubation if necessary.

Answer 56

* Do not attempt to instrument AW outside OR and without surgeon ready to perform emergency tracheostomy * Do not attempt IV, or make cry prior to ready to instrument aiwray * Expect difficult intubation- DAW * **Technique**: * Mask induction- Sevo * Sitting in parent’s lap * Maintain SV * Intubate- Smaller ETT * then IV’s, atropine * Difficulty placing tube → * Rigid bronchoscopy or tracheostomy * Intubated to ICU 24-72 hours, antibiotics, sedated

Answer 57

* Exaggerated reflexive glottic closure * Produced by stimulation of superior laryngeal nerve by → * Blood * Secretions * surgical debris * \*Esp w/ light plane anesthesia * More common in upper airway procedures * **To reduce occurrence:** * IV lidocaine * topical lidocaine * deep extubation * **Management:** * Increase depth of anesthesia * Suction (remove blood/secretions) * 100% FiO2 by tight fitting mask/CPAP - PPV * Jaw thrust * Succs: 0.1-0.5 mg/kg

Answer 58

**supraglottic issue** * Noisy, high-pitched, predominantly inspiratory sound from turbulent airflow from upper AW obstruction * Occurrence: AW diameter * Adult: \< 4-5mm * Management: * 100% oxygen facemask * HOB up * Decrease edema: * Nebulized racemic epi 1 mg 1:1000 solution (1mL) in 5 mL NS (q30 min) * Dexamethasone: 0.1 mg/kg IV q6hrs * Helium (Heliox) → improve laminar flow

Answer 59

* Samter's triad * Nasal polyps * Asthma * Sensitivity to aspirin/NSAIDs → produce bronchospasm

Answer 60

* Typically using topical vasoconstrictors * Samter's triad * Nasal polyps * Asthma * Sensitivity to aspirin/NSAIDs → produce bronchospasm * Significant bleeding * Off NSAIDs/Aspirin

Answer 61

* Smooth wakeup * Prevent PONV * Throat pack placed → ensure removal before extubation * **Topical vasoconstricto**r → reduce bleeding * Can see hemodynamic effects * **Phenylephrine** – alpha adrenergic agonist * Doses high → see HTN * BP monitoring * Vasodilators * Alpha receptors antagonists * Do not use BB → worsen CV output * \***Oxymetazoline** (Afrin) – **selective** alpha 1 agonist/partial alpha 2 agonist * More commonly used c/t phenyl- safer * Spray in nares preop * **AVOID:** * **MAOIs → complications reported**

Answer 62

* VAE * Trauma to eyes * CSF leak * Excess bleeding * Want BP lower * Focal neurologic deficit * Death

Answer 63

* Preop: * evaluate for OSA → AND s/s of LT complications of OSA * nasal polyps (develop NSAID sensitivity and asthma with nasal polyps) * → Life-threatening bronchospasm (Samter’s triad) * Airway management: * GETA * Flexible LMA * MAC

Answer 64

* LA and vasoconstriction * Increased doses cause: * Tachycardia * HTN * mycardial irritability * myocardial depression * Onset 1 min, peak effect 5 min, duration 30-60 min * Usually 4% topical solution * **MAX DOSE: 200 mg**

Answer 65

* alone or w/ lidocaine * Initial dose of phenylephrine should not exceed 0.5mg * May cause severe HTN * **Avoid BB and CCB** * d/t myocardial depression and pulmonary edema * ok to give if oxymet given\*\*\*

Answer 66

* **Epinephrine** * Safe MAX dose: **1.5 mcg/kg (200ug)**

Answer 67

* **Maintenance** * HOB slightly elevated * Deliberate hypotension * Short-acting drugs * **Emergence** * **Remove throat pack**; careful suctioning * Gastric suctioning * Awake extubation to protect airway or “deep” extubation to avoid coughing, bucking * PONV prophylaxis

Answer 68

* Nerve preservation (particularly CN VII, IX, X, XI, XII) * \*Nerve monitoring → mastoidectomy * N2O effect on middle ear * Expansion of space * Control of bleeding * Cant tolerate bc small space * PONV

Answer 69

* Middle ear inflammation and effusion (otitis media) * Surgery: incision in tympanic membrane and insertion of pressure-equalizing (PE) tubes * Anesthesia: * Kids- lack cooperation * Frequently mask inhalation anesthesia _+_ IV started; may give preop PO Midazolam and PR Tylenol * N2O ok→ bc not middle ear

Answer 70

* Tympanoplasty: for perforated tympanic membrane * Stapedectomy: removing the stapes bone and replacing it with a micro prosthesis * Laser precautions * Facial N monitoring * Add remi infusion * Mastoidectomy: to remove an infected portion of the bone or to remove a cholesteatoma or a skin cyst in the ear * Significant BL → hypotn ok * Acoustic neuromas: removal of a vestibular schwannoma **AVOID:** * N2O → diffuse from blood to middle ear → increase ME pressure * Effects tympanic membrane grafts * HTN → increases BL * PONV * NEED: * Smooth wakeup → displace bone prothesis

Answer 71

* Patient understanding and cooperation are ***vital to prevent sudden movement at critical stages of surgery*** * Local anesthesia w/light sedation good for external ear and cooperative patient * GA for middle ear and inner ear * Airway access during procedure limited * Watch head positioning w/ lateral rotation of head * Assess preop for NM problems * GETA preferred for length of sx * Oral RAE * Reinforced or armored tracheal tube – since head turned * Flexible LMA * ProSeal LMA

Answer 72

* Facial nerve monitoring * May not want NDMR * N2O-caution with tympanic grafts * Limit bleeding * Head-up position * Smooth, balanced anesthetic w/ good analgesia * Deliberate hypotension (MAP 50-60) * Keep track of epi doses

Answer 73

* Very high incidence of N/V * PONV prophylaxis * Hydrate * Smooth emergence- no coughing/bucking/retching

Answer 74

* Horizontal fracture of maxilla (involving inferior nasal aperture) extending from: * floor of nose and hard palate * through nasal septum * through pterygoid plates posteriorly * Floor of maxillary sinus/ palate moves * Maxillary alveolus separates from midface

Answer 75

naso-maxillary break - triangular fracture running from the bridge of the nose, through the medial and inferior wall of the orbit, beneath the zygoma/ zygomatic maxillary suture and through the lateral wall of the maxilla and pterygoid plates * Pyramidal fracture/ thru maxillary sinuses

Answer 76

* total separation of midface skeleton from the cranial base * traversing root of the nose, the ethmoid bone, the eye orbits, and the sphenopalatine fossa. * Deep extends through the ethmoid plates and orbits. Cribiform plate may or may not be damaged, extends laterally and upward along the frontal zygomatic sutures and downward and backward to the pterigoid plates…’dish face deformity” * Complete dislocation of maxilla * Face can be caved-in

Answer 77

* AVOID: NASAL AW !!! * Difficult FOB intubation → attempt ETT w/ DL * **Careful for laryngeal trauma:** * s/s laryngeal pain, dyspnea, dysphagia, dysphonia, SQ emphysema, hoarseness * Avoid cricoid pressure * Assess for other trauma: * Pneumothorax

Answer 78

1. Transverse fracture thru floor of maxillary sinuses (only palate moves) 2. Fracture thru maxillary sinuses (pyramidal fracture) 3. Fracture thru orbits (craniofacial dysjunction) * clinically, may be mixed

Answer 79

**LeFort I fractures**: * May be intubated orally or nasally usually without difficulty **LeFort II and III fractures**: * Cranial cavity open and dural tear * S/S: * CSF in nose * blood behind tympanic membrane * periobital edema * “raccoon-eyes” hematoma- signs of fracture and possible passage into the cranial cavity * **CAUTION**: * **Cervical spine stability** → assess * subdural hematoma * pneumothorax * intraabdominal bleeding * Other neurological injuries * **Considerations**: * **Caution NASAL intubation** * May need tracheostomy under LA or awake oral intubation * Expect blood loss and prepare * Post-procedure NO access to oropharyx (due to wiring) * Wire-cutters available

Answer 80

* **Radical neck dissection:** A surgical procedure involving the removal of a [tumor](http://www.medterms.com/script/main/art.asp?articlekey=5863) from the neck with an additional margin of normal [tissue](http://www.medterms.com/script/main/art.asp?articlekey=5800) together with the removal of the [lymph](http://www.medterms.com/script/main/art.asp?articlekey=4212) nodes from the neck. It can involve removal of the mandible and structures in the oropharynx * ![]()The resection included the removal of: * spinal accessory nerve * internal jugular vein * sternocleidomastoid muscle * submandibular gland. * The anatomic structures that remain: * carotid arteries * vagus nerve * hypoglossal nerve * brachial plexus * phrenic nerve. * A more conservative operation involves removing all the lymph nodes but sparing the spinal accessory nerve, sternocleidomastoid muscle, and internal jugular vein. * Total Laryngectomy: * AW ends in blind stoma * Cut end of trachea comes to neck surface * → wakes up with fresh trach

Answer 81

* Cancer patients: → LABS * Emaciated * Dehydrated * Anemic * Assess co-morbidities * LT smoker * Assess difficult airway r/t tumor location and size, radiation therapy, past resections * Eval CT scans * Prepare for position changes with flap reconstruction * Blood available

Answer 82

**Induction** * GETA * surgical tracheostomy at beginning or during the procedure with J shaped laryngectomy tube → sew in * Attn to Peak pressures → freq R mainstem **Maintenance** * A-line and CVP? * Good IV access * Deliberate hypotension * SBP 85-90 * MAP ~ 70 * Head up tilt 10-15 degrees * WATCH for: * air embolism * carotid sinus manipulation * **Ask about surgical nerve stimulator use and NDMR** * Nerve monitoring during dissection phase- *can give at induction nd will wear off during line insertion/positioning* * Technique: * Remifentanil gtt * Sufentanil gtt * TIVA w/ small VA (Propofol) * Caution w/ crystalloid use → contribute to AW edema postop

Answer 83

* New trach irritating and causes coughing * Humidification, regular suctioning, head-up, local * Pain control * PONV prophylaxis * Watch for trauma to R stellate ganglion and cervical ANS

Answer 84

* Thyroid gland regulates body metabolism * Indications: * Cancer, goiter, failed medical mmgt hyperthyroidism * Tx preop for hyperthyroidism → reduce risk of thyroid storm * CV instability * A fib * Ischemia * CHF * Goiter: → CT scan preop \* * Deviation of larynx * Tracheal compression * Horners syndrome * SVC obstruction

Answer 85

* Removal of parathyroid glands * Tracheal compression, * Damage to laryngeal nerves (RLN, ext branch SLN)

Answer 86

* Parathyroidectomy: hypercalcemia/hyperparathyroidism * d/t benign parathyroidadenoma * High Ca preop → lower before sx * Fluids * Lasix * Biphosphinates

Answer 87

**Preop** * Want euthyroid (what medications are used?) * Airway assessment **Induction**- General anesthesia * Blunt SNS responses/ want to depress SNS responses * EMG ETT (nerve testing)- Nerve integrity monitor (NIMs tube) * Use video intubation to position tube perfectly at glottic opening * ?LMA * Advantage: spontaneously breathing patient and can access vocal cord function in real-time * Disadvantage: limited, and possible difficult access to airway

Answer 88

* **Maintenance** * **No muscle relaxation**/ surgical nerve stimulation * No esophageal stethoscope or NGT * Monitor for thyroid storm, compression of trachea * **Emergence** * Smooth with no coughing, bucking

Answer 89

* Hematoma: Airway obstruction * Recurrent laryngeal nerve damage * Unilateral damage- hoarseness * Bilateral damage- Vocal cord paralysis and airway obstruction * AW emergency * Superior laryngeal nerve damage * Voice tires easily, high risk of aspiration * _Hypocalemia_ from inadvertant surgical removal of parathyroid glands * Hypocalcemia * Develops within first 1-72 hrs * Perioral numbness and tingling, paresthesias, mental status changes leading to : * Laryngeal stridor progressing to laryngospasm * FOLLOW preop Ca levels to ensure

Answer 90

* Awake with local * must be a cooperative pt. * technically challenging for surgeon; not ideal * General anesthesia (ideal) * ETT, mask, LMA * avoid muscle relaxation

Answer 91

* **Watch FIO2 and the use of cautery-- airway fire!** * IV Lidocaine prior to trach insertion * Pulling ETT technique * Then cannulate trachea with device * Confirm ETCO2, BBS, O2 sat, airway pressures (Peak inspiratory pressures same when had ETT)

Answer 92

**Fire triad:** * Fuel * Oxygen * Ignition source * Watch drapes – accumulation of O2 * Dry prep time * Sponges/guaze moistened **Steps**: * Immediately remove ETT * Stop flows * Take flammable material away from AW * Pour NS into AW * Fire out → reestablish AW, admin O2, bronch, reintubate * Not going out → CO2 extinguisher

Answer 93

* Smooth * Fresh stoma irritating- pain * Humidification, HOB up, oxygen * CXR * Tracheostomy matures in 5-7 days