ENT aa2 Flashcards
BMT
Bilateral Myringotomy & Tubes (Ear tubes) be careful of knife they use to cut membrane
Cholesteatoma
Clean out infected area of ear (if don,t do can go completely deaf, foul smelling drainage)
Sensory nerves of ear
auriculotemporal n.,
Greater auricular n.,
auricular branch of vagus n.,
tympanic nerve
Local anesthesia for ear surgery
Infiltration w/ lidocaine and epi, topical lido on tympanic membrane, EMLA cream to tm
Prior to making incision for BMT tubes the kids head needs to be
stable (movement is magnified on microscope) usually mask but sometimes use LMA (for longer cases)
N2O in BMT?
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%
What can remifentanyl cause hemodynamic?
Bradycardia
Facial Nerve Monitoring used for?
used during middle ear, mastoid, and inner ear procedures near facial nerve,
NIM (nerve integration monitor) not tube
Facial nerve monitoring NMD blockade?
abolishes nerve activity, SO stop or reverse to increase reliability,
Remifentanil is a good alternative
Types of nasal surgery
external aspect, nasal cavity (polyps, fbs) nasal sinuses, bony structures (fx fixed w/in 10 days, after initial swelling gone)
Problems inherent to ENT
possibility of distorted upper airway or airway obstruction,
competition for airway,
remote airway,
surgical factors-protect airway from blood/secretions, extreme positioning
PONV prophylaxis
Keep hydrated, serotonin antagonists, butyrophenones, scopolamine, dexamethasone, metoclopramide
Inner ear procedures
Cochlea, endolymphatic sac, and labyrinth,
Serious PONV
How to avoid bleeding? can obscure field esp w/ magnification
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)
Name of procedure to clear the sinus opening?
maxillary anstrostomy
Procedure to clear the osteomeatal complex
uncinectomy
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?
Caldwell-Luc
During nasal fx surgery movement can lead to
blindness, carotid artery damage, intracranial damage
Samter’s triad or Aspirin exacerbated Respiratory Disease?
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
common nasal vasoconstrictors and use?
cocaine, epi, phenylephrine, lido w/ epi, reduce bleeding and localize
Why is cocaine unique?
both vasoconstrict and anesthetize
Small doses of cocaine HR?
vagotonic, decrease HR
Higher doses Cocaine CV?
Tachy, htn, Vtach and direct myocardial depression leading to MI VF sudden death
Mech of cocaine for CV effects?
blockage of reuptake of epi at sympathetic nerve terminal and potentiate sympathetic activity
Pt to avoid cocaine?
h/o CAD, NI, CHF, HTN, MAOI
Nasal surgery ETT vs LMA?
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
CORONER’S clot
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
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…
partial or complete, mouth, OSA, NOT severe, dislocation of nasal packing blocking airway
Three devisions of throat, head, and neck procedures
intraoral procedures (tonsillectomy, adenoidectomy, palatal surgery) Laryngeal procedures (laser, endoscopic, benign, malignant, stenosis) Head and neck (parotid, thyroid, nasopharyngeal wall, neck dissection, laryngectomy)
What is Waldeyer’s ring?
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
Why are tonsillectomy perfromed?
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
What may develop min or hours after T & A surgery for obstructed pharynx?
pulmonary edema
OSA signs and complications
simple snoring to upper airway resistance syndrome,
snoring w gasping and choking and silent apneic periods,
severe hypoxemia, hypercarbia, pumonary htn, and cor pulmonale
T & A anesthesia considerations
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
Steroids ENT dose, benefits
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
Incidence of postextubation laryngospasm and stridor ENT
and treatment
12-25% incidence, extubate deep or asleep, avoid stage 2, IV lidocaine to help prevent, subhypnotic doses of propofol, Lasrons maneuver with positive pressure
Postop tonsil bleeding incidence increases with ____, ____, and _____
age (higher in adults), males, and Quinsy (peritonsillar abscess)
Primary bleeds occur with ___ usually venous or capillary
6 hours
Postop tonsil bleed scab falls off at
7-8 days
Suggestive S/S of postop tonsil bleed
unexplained tachy., excessive swallowing, pallor, restlessness, seating, increased cap refill time., hypotension late sign (esp in peds)
Risks for postop tonsil bleeder
hypovolemia,
aspiration risk,
difficult laryngoscopy from clots, oozing, reduced venous and lymph drainage caused swelling,
uneventful initial laryngoscopy may become difficult
Bleeding tonsil management
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
Bleeding tonsil management continued
Decompress stomach,
extubate awake
Laryngeal procedures considerations
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!
Vocal cord pathology
Nodules,
polyps,
cysts,
granulomas (healing trauma tissue from intubation/extubation)
“sac-like” appearance of the fluid-filled vocal cords. The swelling of the vocal folds causes the voice to become deep and horse
Reinke’s edema
What is amyloidosis
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
Presence of stridor indicates airway size of
<4-5mm
Microlaryngoscopy intraop blunting of airway reflexes
htn, tachycardia, dysrhthmias with use of IV or topical lidocaine, narcs, BBs, propofol., MI/Ischemia rate 1.5-4% postop
Emergence microlaryngoscopy
w/o coughing, bucking, breath-holding, laryngospasm
microlaryngoscopy tube MLT
long, small internal and external diameter, size 4-5mm
laser tubes help what?
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
Laser most commonly used for microlaryngoscopy?
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
Fire triad
fuel, oxidant, and ignition (heat) source
with laser use lowest O2 setting to maintain oxygenation. Avoid…
N2O, use air, FIO2<30%
Green lens goggles=
YAG laser
Amber lens goggles=
Argon laser
Clear lens goggles=
CO2
airway fire steps
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,
pulmonary care for airway fire
high humidity, PEEP, steroids, antibiotics, racemic epi
Nonintubation techniques (open)
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
Sander’s type jet injector
16g jet on side arm of laryngoscope or bronchoscope
Supraglottic jet ventilation place _____ cords via suspension larygoscope allows clear view.misalignment leads to
above, poor ventilation, blood, smoke, debris blown into trachea, cant monitor etCO2, risk pneumomediastinum, pneumothorax, SQ emphysema
Subglottic jet vent-small catheter thru _____ into trachea must ensure….
glottis,
min vocal cord movement,
great risk barotrauma than supraglottic,
must ensure entrainment of air and egress of air out of the airway
High frequency ventilation HFV-
small tidal volumes with rapid rates via 3.5-4mm catheter
HFPPV (positive pressure ventilation) resp rates
60-120
HFJV (jet vent) resp rates_____ tidal volumes less than
100-400
dead space
spontaneous vent for ENT
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
Spontaneous ventilation gas removal
use high intensity suction catheter near mouth to clear
Difference in rigid bronchoscopy
better visualization, suction and control of bleeding. Control ventilation due to danger of movement and risk of hypoventilation
rigid bronchoscopy ventilation
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
How long is apneic oxygenation during rigid bronch
limited 2 minutes, scope then removed and pt ventilated, or any time Pa O2 drops
How fast does PCO2 accumulate?
3-4 torr/minute of apnea
Local for bronchoscopy NPO after until
return of gag reflex
over zealous suctioning and hypoventilation from sedation during bronch creates risk of
hypoxemia
Adult tube size for fiberoptic bronch
8.0-9.0
Complications of bronch
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
Complications of bronch
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%
If FB in esophagus, cricoid pressure can cause what?
Can FB cause collapse of trachea?
perforation esp if object is sharp,
yes, if it presses on post tracheal wall (absence of cartilage support)
Inhaled FB organic or inoarganic worse?
organic as it can soften, expand, and fragment, and occlude more lung area
FB removal treatment
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
FB removal treatment urgent
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
Less urgent removal FB
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
Complication of FB removal and treatment
mucosal edema/stridor, humidified O2, racemic epi Txs (may repeat Q30min) Decadron 0.5-1mg /kg may need intubated until edema subsides
etiology of epiglottitis and age
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
what is epiglottitis?
infection of epiglottis and supraglottic structures (arytenoid cartilage mucosa and aryepiglottic folds)
Epiglottitis S/S “four d’s”
dysphasia, dysphonia, dyspnea, and drooling
s/s epiglottitis
look ill,
high fever,
tachy,
neck tender to touch,
stridor maybe on inspiration, NO hoarseness,
Tripod position,
Lateral neck xray “thumb sign” at epiglottis
Start IV in epiglottits?
Only if this can be done without exacerbating the airway compromise (dont make kid cry)
Epiglottitis treat
administer O2 as soon as possible,
induce sevo and 100% with pt in sitting position,
maintain spont resp add CPAP 5-10cm H2O
epiglottis establish adequate depth at induction by looking at
eye signs,
BP and HR,
loss of prominence of intercostal breathing and conversion to quiet diaphragmatic breathing
Epiglottitis intubation
Orally or nasally with tube 0.5-1.0 size smaller than usual
usually remains intubated 24-48hours
Trach uncuff or cuffed for anesthesia?
cuffed needed
immediate complications of trach
bleeding, pneumothorax, surgical emphysema, esophageal perf, misplacement of tube into a false passage, edema, damage RLN
Intermediate complications of trach
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
late complications of trach
tracheal stenosis,
erosion of major blood vessels, erosion of esophagus
trach dislodge in early postop or emergent need to ventilate pt with uncuffed trach
- reintubate through larynx is indicated try smaller tube
2. may pass small 5.5ett through plastic trach tube to establish positive pressure
