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Anesthesia Concepts 4 (Butera) > ENT Anesthesia > Flashcards

ENT Anesthesia Flashcards

1
Q

Hyoid Bone

A

attached to epiglottis and strap muscles

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2
Q

Thyroid cartilage

A

anterior attachment to vocal cords, posterior articulation with cricoid

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3
Q

Cricoid cartilage

A

complete ring, articulates with thyroid and arytenoids

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4
Q

Arytenoids

A

paired, attach to posterior to vocal cords

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5
Q

Anatomy of larynx

A
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6
Q

Superior Laryngeal Nerve

A

Branch of Vagus (CN X)
Sensory laryngeal mucosa above VC, inferior glottis
Motor to Cricothyroid muscle: tenses the vocal cords
Injury results in loss of high register , vocal change

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7
Q

Recurrent Laryngeal Nerve

A

Branch of Vagus
Sensation to Sub-glottis (mucosa below VC)
Motor to intrinsic muscles of the larynx
Injury may result in stridor because of intrinsic muscle paralysis (unilateral v bilateral)

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8
Q

Muscles of Larynx

A
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9
Q

Posterior Cricoarytenoid muscle

A

When the PCA muscles contract, they swivel the arytenoids around on their axes, causing the vocal cords to ABDUCT (pull apart laterally). It is the only muscle that abducts the cords.

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10
Q

Lateral Cricoarytenoid Muscle

A

Because of its different orientation compared to the posterior cricoarytenoid muscle, it will internally rotate the arytenoids and cause ADDUCTION (bring together) the vocal cords.

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11
Q

Intrinsic Muscles Actions

A

Thyroarytenoids relax the VC

Cricothyroid adduct and tense the VC

Lateral Cricoarytenoid Adduct the VC

Posterior Cricoarytenoid Abduct the VC

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12
Q

Upper Airway Muscles and their function

A

Tensor Palatine: Opens the nasopharynx

Genioglossus: Opens the oropharynx

Hyoid Muscles: Opens the hypopharynx

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13
Q

Laryngospasm

A

Exaggeration of the normal glottis closure reflex that persists long after removal of the stimulus

Reflex glottis closure is produced by the superior laryngeal nerve

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14
Q

Risk factors for Laryngospasm

A

Pre op: Active or recent URI (<2wk)
Second hand smoke, Reactive airway disease, GERD, Age < 1 year

Intraoperative: light anesthesia, FB in airway, Hyperventilation/ hypocapnea, procedures on the airway.

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15
Q

Strategies to prevent Laryngospasm

A

IV or topical Lidocaine
Avoid stimulation during light anesthesia
Suction oropharynx prior to extubation
Tracheal extubation when fully awake
Administer 100% oxygen for 3-5 minutes prior to extubation

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16
Q

Step by step management of laryngospasm

A

A. Immediate suction and removal of debris
B. Application of 100% O2 with jaw thrust using bilateral digital pressure on the mandible
C. When A and B fail and O2 Sat continues to fall increase anesthesia depth with iv propofol and/or a small dose of succinylcholine 0.1-0.05mg/kg

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17
Q

Airway maneuvers

A

Larsen’s
Valsalva: Exhalation against a closed glottis

Muller’s: Inhalation against a closed glottis

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18
Q

Boarders of Larsen’s Maneuver

A

Posterior: Mastoid process
Anterior: Ramus of Mandible
Superior: Skull base

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19
Q

What is stridor? Management?

A

Noisy inspiration related to turbulent gas flow

MANAGEMENT
O2 by facemask, head up 45-90 degrees
Nebulized racemic epinephrine
Dexamethasone 4-8mg q 8-12 hours
Heliox (70% he 30% O2)

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20
Q

What is stridor? Management?

A

Noisy inspiration related to turbulent gas flow

MANAGEMENT
O2 by facemask, head up 45-90 degrees
Nebulized racemic epinephrine
Dexamethasone 4-8mg q 8-12 hours
Heliox (70% he 30% O2)

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21
Q

PEARLS of parotid surgery

A

Patients can have inflammatory disorders or lesions of the parotid
Facial nerve preservation
Short term muscle relaxation or none
Return of train of four or full return before dissection

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22
Q

Facial Nerve Branches

A
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23
Q

quick facts about head and neck cancer

A

Represents 5% of all human cancers

Most patients are between 50-80 years old

Men outnumber women 2:1

24
Q

Examples of head and neck surgeries and common comorbidities among these patients

A

Includes laryngectomy, radical neck dissection, hemimandibulectomy and radical sinus surgery

Considerations
Heavy smokers and users of alcohol
Pulmonary disease
Malnutrition
Anemia
Difficult Intubation

25
Q

anesthesia considerations for head and neck surgery

A

Vagal response from carotid artery manipulation

Open neck veins may create air emboli

May require tracheostomy as a part of the procedure or to avoid airway edema from extensive surgical manipulation

26
Q

Tracheostomy is ____

A

an airway that is inserted subglottically through neck tissues directly into the trachea.

27
Q

Surgical Tracheostomy involves _____

A

dissection and incision of trachea under direct vision.

28
Q

Percutaneous Tracheostomy involves _____

A

Seldinger technique and dilatation of trachea.

29
Q

For the first two weeks, all tracheostomy changes should be done _____

A

in OR with anesthesia provider present

30
Q

Neck Dissection

A

To remove cancer that has spread to lymph nodes in the neck

Radical vs. Modified Radical Neck Dissection
Radical: lymph nodes of the neck, sternocleidomastoid muscle, internal jugular vein, and spinal accessary nerve are removed.

31
Q

Flap Reconstruction

A

Where is the donor site?

Common pedicle flaps include; cervicothoracic, pectoralis major, sternocleidomastoid, and temporoparietal
A free flap is removed from a distant site
Microsurgery is required to reconstruct vascular supply

32
Q

Anesthesia Considerations for Flap Reconstructions

A

Long procedures
Fluid and temperature management
Arterial line and two large IV’s
Tracheostomy is usually performed
Muscle relaxants are avoided
Vasoconstrictors are avoided (? dobutamine)
Transfusions are avoided to minimize micro thrombosis

33
Q

Panendoscopy PEARLS

A

Anticipate difficult intubation
Communicate with surgeon
Techniques:
Mask with volatile agent when deep surgeon preforms endoscopies
Conventional GETA
Remifentanil a short acting mu-opioid analgesic

34
Q

Microlaryngoscopy

A

Goal to provide the surgeon with a clear view an immobile field and room to work

The anesthetist must protect the trachea, ensure good ventilation and oxygenation minimize secretions and reflexes and promote rapid awaking and return of protective airway reflexes

35
Q

Fire Triangle =

A
36
Q

Laser Safety

A

Use < 30% FIO2 Air/Oxygen. NOT N2O
H2O or saline available
Most ETT are flammable
Laser resistant ETT are not laser proof
The cuff is most vulnerable to damage
Laser ETT cuff filled with water +/- dye
Laser ETT do not protect against electrocautry
Eye care: taped close no petroleum lube, covering with saline soaked gauze, and protective glasses

37
Q

CO2 laser

A

wavelength: 10,600 um
type of surgery: Oropharyngeal, Vocal Cord
structure damaged: Cornea
eye protection: clear lenses

38
Q

Nd:YAG laser

A

wavelength: 1064 um
type of surgery: Tumor Debulking, Tracheal
structure damaged: retina
eye protection: green goggles

39
Q

Ruby laser

A

wavelength: 694 um
type of surgery: retinal
structure damaged: retina
eye protection: red goggles

40
Q

Argon laser

A

wavelength: 515 um
type of surgery: vascular lesions
structure damaged: retina
eye protection: amber goggles

41
Q

Anesthesia for nasal and sinus surgery

A

GETA is usually preferred for procedures such as endoscopic sinus surgery

Considerations
Blood in the oropharynx at the time of extubation may lead to coughing or laryngospasm
Throat pack can reduce the amount of blood entering the glottis
Blood collections can occlude the glottis after extubation and result in airway obstruction

42
Q

Pre-op eval and technique for tonsillectomy

A

Preoperative evaluation: loose teeth and checking coagulation variables

Standard technique: Deep GA that prevents reflex induced hypertension tachycardia and arrhythmias. Muscle relaxation??. Rapid recovery and return of protective airway reflexes.
LMA (reinforced flexible)
Pediatric “tonsil position”

43
Q

Tonsillectomy Complication: bleeding

A

BLEEDING
Incidence requiring surgery 0.3-0.6%
Usually occur within 6 hours of surgery
Blood loss is underestimated

Anesthesia
Check coagulation, type and cross, good IV access, adequate hydration before induction, RSI with cricoid pressure, slight head down, and extubate when patient is awake

44
Q

Tonsillectomy Complication: PONV

A

Incidence as high as 70% during the first 24 hours after tonsillectomy
Dexamethasone
Metoclopramide
Ondansetron
N2O
Decompress the stomach

45
Q

Tonsillectomy in Children

A

More than 289000 preformed on children younger than 15

Recommendations important to anesthesia
IV Dexamethasone
Against perioperative antibiotics
Importance of pain management after tonsillectomy

46
Q

Cleft Lip and Palate Surgery

A

A common craniofacial abnormality occurring in 1:700 births, bones of the face develop in the fifth and ninth weeks, and the palatal development in the sixth to eleventh weeks

Up to 30% of these newborns have other congenital anomalies such as Downs syndrome, Pierre Robin and Treacher Collins syndrome

47
Q

Pierre Robin

A

Small mandible = micrognathia or mandibular hypoplasia
Glossoptosis: A tongue that falls back and downward
Cleft Palate
Neonate often requires intubation

48
Q

Main Characters of Pierre Robin Syndrome

A
49
Q

Treacher Collins

A

A genetic condition caused by changes in gene on chromosome 5 which affects facial development
Downward slanted eyes small jaw and chin unusually formed or absent ears hearing loss and cleft palate
May present for plastic surgery

Small mouth, small underdeveloped mandible
Nasal airway is blocked by tissue (choanal atresia)
Ocular and auricular anomalies

50
Q

Trisomy 21

A

John Langdon Down published in 1866 the first accurate description of a person afflicted with the syndrome
In Down’s syndrome the cell contains 47 chromosomes with an extra chromosome linked to chromosome 21, resulting in trisomy 21

Small mouth
Large tongue
Atlantoaxial instability
Small subglottic diameter (subglottic stenosis)

51
Q

Timing of Cleft Lip Closure

A

Cleft lip usually at 3 mm of age to allow to feed and demonstrate facial expressions
Closure of the hard and soft palate 5-8mm age for speech development

52
Q

Anesthesia Considerations for CleftLip and Palate

A

PREOP Guidelines: Rule of 10’s
Weight 10 lbs, hemoglobin10 mg/dl, white cell count < 10,000/mm3, and more than 10 weeks

Laryngoscope may slip into cleft
Oral RAE ETT taped to lower lip
Eye care
Tongue suture to avoid oral airway

Cleft lip may have a Logan Bow placed at the end of procedure, this makes mask ventilation difficult to impossible

53
Q

Dingman-Dott Retractor

A

Can reduce venous drainage and cause tongue swelling
Post op airway obstruction

54
Q

Anesthesia for ear surgery

A

Anesthesia can be by infiltration of local anesthetic or by general anesthesia

Premeatal operations, stapedectomy, and uncomplicated middle ear surgery can be preformed with local anesthesia

55
Q

General anesthesia for ear surgery

A

Positioning of the the patient

Preservation of the facial nerve
N2O and middle ear pressure

Nausea and vomiting

56
Q

Myringotomy

A

Commonly preformed pediatric surgical procedure

Short surgical procedure under GA by face mask

Treat postoperative discomfort by: acetaminophen 40/kg PR, intranasal fentanyl 2mcg/kg

Anesthesia Concepts 4 (Butera) (15 decks)

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