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ENT aa2 Flashcards

1
Q

BMT

A

Bilateral Myringotomy & Tubes (Ear tubes) be careful of knife they use to cut membrane

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2
Q

Cholesteatoma

A

Clean out infected area of ear (if don,t do can go completely deaf, foul smelling drainage)

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3
Q

Sensory nerves of ear

A

auriculotemporal n.,
Greater auricular n.,
auricular branch of vagus n.,
tympanic nerve

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4
Q

Local anesthesia for ear surgery

A

Infiltration w/ lidocaine and epi, topical lido on tympanic membrane, EMLA cream to tm

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5
Q

Prior to making incision for BMT tubes the kids head needs to be

A

stable (movement is magnified on microscope) usually mask but sometimes use LMA (for longer cases)

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6
Q

N2O in BMT?

A

diffuses into middle ear, increases pressure- great idea for BMT
pressure relieved by reabsorption after d/c or by eustachian tube venting,
Negative pressures produced by rapid reabsorption can displace graft,
Most avoid or limit to <50%

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7
Q

What can remifentanyl cause hemodynamic?

A

Bradycardia

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8
Q

Facial Nerve Monitoring used for?

A

used during middle ear, mastoid, and inner ear procedures near facial nerve,
NIM (nerve integration monitor) not tube

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9
Q

Facial nerve monitoring NMD blockade?

A

abolishes nerve activity, SO stop or reverse to increase reliability,
Remifentanil is a good alternative

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10
Q

Types of nasal surgery

A 
external aspect,
nasal cavity (polyps, fbs)
nasal sinuses,
bony structures (fx fixed w/in 10 days, after initial swelling gone)
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11
Q

Problems inherent to ENT

A

possibility of distorted upper airway or airway obstruction,
competition for airway,
remote airway,
surgical factors-protect airway from blood/secretions, extreme positioning

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12
Q

PONV prophylaxis

A 
Keep hydrated,
serotonin antagonists,
butyrophenones, 
scopolamine,
dexamethasone,
metoclopramide
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13
Q

Inner ear procedures

A

Cochlea, endolymphatic sac, and labyrinth,

Serious PONV

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14
Q

How to avoid bleeding? can obscure field esp w/ magnification

A

Head up reduce venous pressure,
ASA I hypotensive tech. : MAP 50-60, intraoposystolic > preop diastolic, HR 60
Agents: BB(metoprolol, labetolol), clonidine, opioids (remi drip)

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15
Q

Name of procedure to clear the sinus opening?

A

maxillary anstrostomy

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16
Q

Procedure to clear the osteomeatal complex

A

uncinectomy

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17
Q

What is the fenestration of the anterior wall of the maxillary sinus and the surgical drainage of this sinus into the nose via an antrostomy?

A

Caldwell-Luc

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18
Q

During nasal fx surgery movement can lead to

A

blindness, carotid artery damage, intracranial damage

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19
Q

Samter’s triad or Aspirin exacerbated Respiratory Disease?

A

ASA and other non-steroidal anti-inflammatory drugs (NSAIDS) sensitivity in pts with asthma and recurrent sinus disease with nasal polyps leading to severe bronchospasm

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20
Q

common nasal vasoconstrictors and use?

A 
cocaine,
epi, 
phenylephrine,
lido w/ epi,
reduce bleeding and localize
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21
Q

Why is cocaine unique?

A

both vasoconstrict and anesthetize

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22
Q

Small doses of cocaine HR?

A

vagotonic, decrease HR

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23
Q

Higher doses Cocaine CV?

A

Tachy, htn, Vtach and direct myocardial depression leading to MI VF sudden death

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24
Q

Mech of cocaine for CV effects?

A

blockage of reuptake of epi at sympathetic nerve terminal and potentiate sympathetic activity

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25
Q

Pt to avoid cocaine?

A

h/o CAD, NI, CHF, HTN, MAOI

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26
Q

Nasal surgery ETT vs LMA?

A

Potential for bloody contamination of lower airway,
RAE tube,
Flexible LMA in experienced hands (may result in less lower airway blood contamination then ett)
Extubate awake, suction thoroughly

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27
Q

CORONER’S clot

A

Throat pack sometimes used and make sure it is out before exutbation,
Inspect oral cavity and postnasal space for blood by standard laryngoscopy and suction catheter behind soft palate,
Any clot left behind can be inhaled after ett removed and lead to total airway obstruction and death

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28
Q

Nasal pacts and lead to _____ or _____ obstruction. Instruct patient to breath through _____. Can be more problematic in ____ patients. Postop pain?
If respiratory depression after ett removal, consider…

A 
partial or complete,
mouth,
OSA,
NOT severe,
dislocation of nasal packing blocking airway
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29
Q

Three devisions of throat, head, and neck procedures

A 
intraoral procedures (tonsillectomy, adenoidectomy, palatal surgery)
Laryngeal procedures (laser, endoscopic, benign, malignant, stenosis)
Head and neck (parotid, thyroid, nasopharyngeal wall, neck dissection, laryngectomy)
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30
Q

What is Waldeyer’s ring?

A

Ring of lymphoid tissue around pharynx made up of
palatine tonsils, nasopharyngeal tonsil (adenoid)
and lingual tonsil,
with tubal tonsils
and lateral pharyngeal bands as less prominent component

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31
Q

Why are tonsillectomy perfromed?

A

Frequently performed done for recurrent tonsillitis, peritonsillar abscess, OSA and bx
Adenoidectomy needed less in adults d/t postnasal space enlarges
adult more pain from scarring and fibrosis

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32
Q

What may develop min or hours after T & A surgery for obstructed pharynx?

A

pulmonary edema

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33
Q

OSA signs and complications

A

simple snoring to upper airway resistance syndrome,
snoring w gasping and choking and silent apneic periods,
severe hypoxemia, hypercarbia, pumonary htn, and cor pulmonale

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34
Q

T & A anesthesia considerations

A

mask induction slower with OSA esp w loss of upper airway tone,
FIO<30%
RAE or flex LMA,
antibiotics not usually,
goal allow insertion of mouth gag and avoid reflex tachy and htn,
fentanyl propofol +/-NMBD

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35
Q

Steroids ENT dose, benefits

A 
0.05 to 0.15mg/kg (PONV dose)
or 0.5-1mg/kg upt to max of 20mg for ENT,
less PONV,
better diet tolerance,
Reduced PAIN
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36
Q

Incidence of postextubation laryngospasm and stridor ENT

and treatment

A 
12-25% incidence,
extubate deep or asleep, avoid stage 2,
IV lidocaine to help prevent,
subhypnotic doses of propofol,
Lasrons maneuver with positive pressure
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37
Q

Postop tonsil bleeding incidence increases with ____, ____, and _____

A

age (higher in adults), males, and Quinsy (peritonsillar abscess)

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38
Q

Primary bleeds occur with ___ usually venous or capillary

A

6 hours

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39
Q

Postop tonsil bleed scab falls off at

A

7-8 days

40
Q

Suggestive S/S of postop tonsil bleed

A

unexplained tachy., excessive swallowing, pallor, restlessness, seating, increased cap refill time., hypotension late sign (esp in peds)

41
Q

Risks for postop tonsil bleeder

A

hypovolemia,
aspiration risk,
difficult laryngoscopy from clots, oozing, reduced venous and lymph drainage caused swelling,
uneventful initial laryngoscopy may become difficult

42
Q

Bleeding tonsil management

A

Get experienced help,
Give oxygen, fluid resuscitate, check H&H, coag, T&C,
Extra laryngoscope, assorted blades, tubes,
TWO SUCTIONS,
RSI, head down if tolerated,
mask induction with pt lateral or head down option for experienced provider

43
Q

Bleeding tonsil management continued

A

Decompress stomach,

extubate awake

44
Q

Laryngeal procedures considerations

A

shared space anesthesia and surgeon,
range of pts from young and fit to elderly with glottic carcinoma and stridor,
CLOSE COMMUNICATION AND COOPERATION A MUST!

45
Q

Vocal cord pathology

A

Nodules,
polyps,
cysts,
granulomas (healing trauma tissue from intubation/extubation)

46
Q

“sac-like” appearance of the fluid-filled vocal cords. The swelling of the vocal folds causes the voice to become deep and horse

A

Reinke’s edema

47
Q

What is amyloidosis

A

a condition in which abnormal proteins (called amyloids) become deposited in the spaces between cells. either in larynx or larynx and pharynx look like yellowsih candle wax within tissues

48
Q

Presence of stridor indicates airway size of

A

<4-5mm

49
Q

Microlaryngoscopy intraop blunting of airway reflexes

A

htn, tachycardia, dysrhthmias with use of IV or topical lidocaine, narcs, BBs, propofol., MI/Ischemia rate 1.5-4% postop

50
Q

Emergence microlaryngoscopy

A

w/o coughing, bucking, breath-holding, laryngospasm

51
Q

microlaryngoscopy tube MLT

A

long, small internal and external diameter, size 4-5mm

52
Q

laser tubes help what?

A

protect from airway fire. All metal except for cuff and connector-venerable points. Double cuffs, filled with NSS and methylene blue act as a heat sink and identify breeching of cuff

53
Q

Laser most commonly used for microlaryngoscopy?

A

CO2 laser, hazardous to pt and OR personnel. Risk of laser induced airway fire and stray laser beam hazardous to OR personnel
pt face and neck protected w/ wet gauze or towel, tape eyes, clear lens for personnel

54
Q

Fire triad

A

fuel, oxidant, and ignition (heat) source

55
Q

with laser use lowest O2 setting to maintain oxygenation. Avoid…

A

N2O, use air, FIO2<30%

56
Q

Green lens goggles=

A

YAG laser

57
Q

Amber lens goggles=

A

Argon laser

58
Q

Clear lens goggles=

A

CO2

59
Q

airway fire steps

A

disconnect circuit-fastest way to stop flow of oxygen,
extubate (submerge tube in water) and ventilate with mask/new circuit
Reintubate/bronchoscope to assess and remove debris,

60
Q

pulmonary care for airway fire

A

high humidity, PEEP, steroids, antibiotics, racemic epi

61
Q

Nonintubation techniques (open)

A

venturi effect entrains air along with pressurized O2 @ 30-50 psi,
surgeon directs tip avoiding barotrauma and gastric distention,
NOT for obese, emphysema , large tumors,
place LMA for emergence

62
Q

Sander’s type jet injector

A

16g jet on side arm of laryngoscope or bronchoscope

63
Q

Supraglottic jet ventilation place _____ cords via suspension larygoscope allows clear view.misalignment leads to

A 
above,
poor ventilation,
blood, smoke, debris blown into trachea,
cant monitor etCO2,
risk pneumomediastinum, pneumothorax, SQ emphysema
64
Q

Subglottic jet vent-small catheter thru _____ into trachea must ensure….

A

glottis,
min vocal cord movement,
great risk barotrauma than supraglottic,
must ensure entrainment of air and egress of air out of the airway

65
Q

High frequency ventilation HFV-

A

small tidal volumes with rapid rates via 3.5-4mm catheter

66
Q

HFPPV (positive pressure ventilation) resp rates

A

60-120

67
Q

HFJV (jet vent) resp rates_____ tidal volumes less than

A

100-400

dead space

68
Q

spontaneous vent for ENT

A

useful for fb removal, eval of airway, removal of simple glottic lesions,
mask induction with sevo, LTA spray cords,
Insufflation of agent with sm cath placed nasally, nasal pharyngeal airway, shortened ett placed nasally, or side arm of scope

69
Q

Spontaneous ventilation gas removal

A

use high intensity suction catheter near mouth to clear

70
Q

Difference in rigid bronchoscopy

A

better visualization, suction and control of bleeding. Control ventilation due to danger of movement and risk of hypoventilation

71
Q

rigid bronchoscopy ventilation

A

glass lens must be placed over optical outlet, less gases will be aimed at operator.
ETCO2 will not return via circuit. Ensure adequate ventilation-adequate oxygenation doesnt equal
use muscle relaxants

72
Q

How long is apneic oxygenation during rigid bronch

A

limited 2 minutes, scope then removed and pt ventilated, or any time Pa O2 drops

73
Q

How fast does PCO2 accumulate?

A

3-4 torr/minute of apnea

74
Q

Local for bronchoscopy NPO after until

A

return of gag reflex

75
Q

over zealous suctioning and hypoventilation from sedation during bronch creates risk of

A

hypoxemia

76
Q

Adult tube size for fiberoptic bronch

A

8.0-9.0

77
Q

Complications of bronch

A

bronchospasm,
hypoxemia,
CO2 retention,
Resistance to ventilation if FOB occupies too much cross section of ett or scope too tight in larynx, PEEP occurs, decreases venous return and C.O

78
Q

Complications of bronch

A 
bronchospasm,
hypoxemia,
CO2 retention,
Resistance to ventilation if FOB occupies too much cross section of ett or scope too tight in larynx, PEEP occurs, decreases venous return and C.O,
Trauma of pneumothorax,
pneumomediastinum, SQ emphysema,
Intraop awareness 1-2%
79
Q

If FB in esophagus, cricoid pressure can cause what?

Can FB cause collapse of trachea?

A

perforation esp if object is sharp,

yes, if it presses on post tracheal wall (absence of cartilage support)

80
Q

Inhaled FB organic or inoarganic worse?

A

organic as it can soften, expand, and fragment, and occlude more lung area

81
Q

FB removal treatment

A

100% O2, robinul or atropine,
no preop sedation, no N2O,
Awake laryngoscopy,
In near complete occlusion pushing laryngeal/tracheal fb into mainstem bronchus has resulted in reducing obstruction temporarily

82
Q

FB removal treatment urgent

A

100% O2, robinul or atropine,
no preop sedation, no N2O,
Awake laryngoscopy,
In near complete occlusion pushing laryngeal/tracheal fb into mainstem bronchus has resulted in reducing obstruction temporarily

83
Q

Less urgent removal FB

A

IV or mask induction,
spontaneous resp maintained,
in know organic material, position lateral w/ affected side down to minimize fragment spread,
brief period of NMB maybe needed

84
Q

Complication of FB removal and treatment

A 
mucosal edema/stridor,
humidified O2,
racemic epi Txs (may repeat Q30min)
Decadron 0.5-1mg /kg
may need intubated until edema subsides
85
Q

etiology of epiglottitis and age

A

Bacterial: Haemophilus influenza type B (less now) and Group A strep. Viral cuase is parainfluenza virus
Age 3-5yo, although seen in all ages, peaks in spring and fall

86
Q

what is epiglottitis?

A

infection of epiglottis and supraglottic structures (arytenoid cartilage mucosa and aryepiglottic folds)

87
Q

Epiglottitis S/S “four d’s”

A

dysphasia, dysphonia, dyspnea, and drooling

88
Q

s/s epiglottitis

A

look ill,
high fever,
tachy,
neck tender to touch,
stridor maybe on inspiration, NO hoarseness,
Tripod position,
Lateral neck xray “thumb sign” at epiglottis

89
Q

Start IV in epiglottits?

A

Only if this can be done without exacerbating the airway compromise (dont make kid cry)

90
Q

Epiglottitis treat

A

administer O2 as soon as possible,
induce sevo and 100% with pt in sitting position,
maintain spont resp add CPAP 5-10cm H2O

91
Q

epiglottis establish adequate depth at induction by looking at

A

eye signs,
BP and HR,
loss of prominence of intercostal breathing and conversion to quiet diaphragmatic breathing

92
Q

Epiglottitis intubation

A

Orally or nasally with tube 0.5-1.0 size smaller than usual

usually remains intubated 24-48hours

93
Q

Trach uncuff or cuffed for anesthesia?

A

cuffed needed

94
Q

immediate complications of trach

A 
bleeding, pneumothorax,
surgical emphysema,
esophageal perf,
misplacement of tube into a false passage,
edema,
damage RLN
95
Q

Intermediate complications of trach

A

infection,
misplacement of tube,
trach ties are not be changed for first 7 days a collapse of tissue around stoma makes correct passage hard to find

96
Q

late complications of trach

A

tracheal stenosis,

erosion of major blood vessels, erosion of esophagus

97
Q

trach dislodge in early postop or emergent need to ventilate pt with uncuffed trach

A
  1. reintubate through larynx is indicated try smaller tube

2. may pass small 5.5ett through plastic trach tube to establish positive pressure

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