ENT and Eye Flashcards
Basic part of the ear
3
- Inner
- Middle
- Outer
Basic Inner Ear anatomy
Cochlea
Cochlear nerve
Vestibular nerve
Eustachian tube
Basic Middle Ear anatomy
Semicircular canals
Eustachian tube
Stapes
Incus
Malleus
Tympanic membrane
SIM-> Proximal to distal
Basic Outer Ear anatomy
External acoustic meatus
Temperal bone
External ear surgeries
Reconstruction of ear or auditory canal
GA with LMA and local
Middle Ear procedures: OCR
Ossicular chain reconstruction (OCR) is a surgical method used to repair conductive hearing loss.
Middle Ear procedures: Myringotomy and Tube Insertion
Classic BMT
Helps drain middle ear because the eustachian tube isnt working
Facemask induction for shorter cases. LMA or ETT for longer ones
Middle Ear procedures: Cholesteatoma
Cholesteatoma is a skin-lined cyst that begins at the margin of the eardrum and invades the middle ear and mastoid
Middle Ear procedures: Stapedectomy
Stapedectomy is a surgical procedure to treat hearing loss caused by otosclerosis
Inner Ear Procedures: Neoplasm or chochlear implant
Meneirs Dx: common issues with Labyrinth/Semicurcular canals
Complex, GA with muscle relaxation
Increased PONV risk
A microscope is common in ear surgery. What things do we have an impact on while the doc is working under the scope?
Movement: Relaxation
Breathing: Spontaneous / Belly breathing
Ear surgery considerations
Avoid coughing
NO N2O
Increased PONV risk
Monitoring negates use of NMB’s
Basic Nasal Anatomy
Sinus Anatomy
4 types of nasal surgery
- External
- Nasal Cavity
- Nasal Sinus
- Nasal Bony Structures
LMA’s in Nasal surgery?
No, they get in the way. Use an ETT and tape it to the side
Nasal Surgery: Throat packs
Remove BEFORE wakeup
OG tubes sometimes used
Nasal Surgery: Nasal ETT or Nasal Airway
Do not use
Throat surgery: Pearls
- Decadron for swelling, pain, PONV (0.05-0.15mg/kg)
- Abx not indicated
- NMB not indicated
- NSAIDS (minus aspirin) are fine
Throat surgery: Complications
- Post extubation laryngospasms
- Bleeding Tonsils
- Reintubation difficult (swelling and bleeding)
How can we decrease post extubation spasms?
LITIES
- Lay on side, decrease secretions on vocal chords
- IV Lido 1mg/kg
- Topical Lido 4mg/kg
- IV Magnesium (not really just in the book)
- Ensure proper narc level
- Small bolus of propofol
General info on bleeding tonsils
Venous in nature
bleeds more often in adult males (2-5%)
Usually in a 6 hour window
Blood loss is hard to measure since it is swallowed
Check H/H if low
Use smaller ETT if reintubating
OG Tube for blood in stomach
Vocal Cord surgeries
Pathology: Bx and resections
Injections: for RLN/Cord dysfunction (usually a filler)
Types of tubes: MLT
Micro Laryngeal Tube
Smaller in diameter, less in the way
Types of tubes: Dual cuff laser
Yellow cuff: air
Clear cuff: saline
Sometimes add dye to saline to see if ruptured easier
Types of tubes: Armored
won’t kink but can be compromised by compression
Types of tubes: Montandon
J shaped and inserted into a temp tracheostomy if larynx is to be removed.
Head and Neck considerations
- Usually for cancer resections
- avoid jugular veins for central line
- carotid sinus may be manipulated
- risk for blood loss
- neuromonitoring common
- airway issues by manipulations, lesions, or radiation scarring
- Remifent infusions are great for these
Tracheostomy steps
6
- Dissection down to trachea
- We advance ETT further to avoid puncture
- Doc has us SLOWLY retract for visualization
- Once our tube goes past they will introduce the trach device
- Leave out tube just past the vocal cords for emergency
- Disconnect circuit and pass to surgeon. Confirm EtCO2
Three parts to a trach tube
- Outer cannula
- Obturator
- Inner cannula
Cuffed with disposable inner cannula
Used to obtain a closed circuit for ventilaiton
Cuffed with resuable inner cannula
Used to obtain a closed circuit for ventilaiton
Cuffless with disposable inner cannula
Used in pts with tracheal problems and pts ready for removal of trach tube
Cuffless with resuable inner canula
Used in pts with tracheal problems and pts ready for removal of trach tube
Fenestraded cuffed
Pts on the vent but are not able to tolerate a speaking valve
Fenestrated cuffless
Used for pts who have difficulty with a speaking valve
Which type of trach tube is in most patients?
Cuffless
Which type of trach tube is needed to PPV?
Cuffed, needed to make a seal
Why don’t we replace a trach tube if it is still new?
Tissues inflammed and can create a flase passage
May close before we can get a new one in
Info printed on trach tubes?
Manufacture (Shiley)
Size (inner diamter i.e. 8)
DCT: dual cannula tracheostomy
I.D.: inner diameter (mm)
O.D.: outer diameter (mm)
Tube length: XLT Proximal or Distal
What the heck does an XLT Proximal indication on a trach tube mean?
Longer proximally because the pt has a thick neck
What the heck does an XLT Distal indication on a trach tube mean?
Longer distally to help bypass a stenotic trachea
OMFS?
Oral and Maxillofacial Surgery
OMFS surgeries
Cleft palate
jaw deformity
facial trauma
oral cancer
dental procedures
What is a LeFort fx?
facial fx, 3 types
Don’t need to know the 3 types
Cleft Palate / LeFort pearls
High risk for blood loss
Usually young healthy pts: permisive hypotension
Tons of Local used with high amounts of EPI
Most often nasal RAE used
Remi infusions good here
What does RAE stand for?
Ring Adair Elwyn
OMFS trauma
Usually a zygomatic arch or mandible fx
OMFS trauma management
Bleeding not always an issue
massive exposure and plating
nasal rae
throat pack
wired jaw
What do we make sure of before wiring the jaw shut?
Throat pack is removed and we have wire cutters ready to go
To Zanzibar By Motor Car
Facial nerve branches
- Temporal
- Zygomatic
- Buccal
- Mandibular
- Cervical
Eye cranial nerves: CN 2
Optic Nerve
neural signal from retina
Eye cranial nerves: CN 3
Oculomotor Nerve
Eye cranial nerves: CN 4
Trochlear Nerve
Eye cranial nerves: CN 5
Trigeminal
touch and pain
Eye cranial nerves: CN 6
Abducens
controls extrinsic eye muscles
IOP normal pressure?
10-20mmHg
Does blood flow increase or decrease with a reduction in IOP?
Increase
Oculocardiac Reflex
retraction on eye muscles causes profound bradycardia via the trigeminal to vagus route
Medial Rectus muscle more profound, possible with injections
How do we overcome the oculocardiac reflex
Stop retracting
0.2mg Glyco
Acetazolamide
carbonic anhydrase inhbitor
deceases IOP for glaucoma
Echothiphate
topical anticholinesterase
treats glaucoma
Chronic use will lead to prolonged succs effects
Pilocarpin and Acetylcholine
Cholinergic agonists
constricts pupil
Bradycardia and bronchospasm may occur with use
Timolol
BB for glaucoma
Bronochospasm, bad for CHF and COPD
Cataract surgery
No blood loss, little pain, extreme anxiety as pt is awake
HTN and T2D common in pt population
Possible pulmonary issues when lying flat
Coughing an issue
OSA potential issue
Regonal Anesthesia for eye surgeries
Facial nerve block
Retrobulbular block
Posterior Peribublar
Sub-Tenon block
Facial Nerve Blocks
van Lint
O’Brien
Nadbath-Rehman
prevents eye movement
Just know these names
Retrobubular Blocks
Retrobubular hemorrhage may occur
IOP can increase
IV injection possible (small dose no worry for LAST)
Intra-arterial injection possible (will cause transient seizure)
prevents movement and good analgesia
Posterior Peribubular Blocks
Modified retrobubular with lower hemorrhage risk
two different injection sites
longer onset
potential for incomplete block of movement
Sub-Tenon Block
Sedation and topical anesthesia needed for this
much longer onset but most profound
Sedation for blocks
Benzo’s: Versed (low doses) or PO Alprazolam, Diazepam
Fent: 12.5-50 mcg / Alfentanil: 50-100 mcg
Prop: 30-50 mg
What needle is used for a retrobulbular block?
Atkinson Needle
Two types of anesthetic drops?
Tetracaine 0.5%
Lidocaine 4%
Pros and Cons of LMA for eye surgery
Can get in the way of doc
less secure
more potential for spasms
LMA spontaneous vent can cause rocking under the microscope
Spontaneous vent does not cause increase in IOP
Pros and Cons of ETT for eye surgery
Can be bent out of the way for doc
more secure
airway protected against spasms
PPV more stable under microscope
PPV can increase IOP
N2O in eye surgery
Avoid completely
Two gases used for vitreous gas bubbles
Sulfur hexafluoride
Perfluoropropane
