ENT, Laser, and Jet Ventilation Flashcards
Turbinates divide nasal cavity in to how many different compartments?
3
What are the three compartments of the nasal cavity divided by the turbinates?
superior, middle, and inferior
What about the nasal turbinates has implications for CRNAs?
they’re highly vascular
What are the four paired sinuses of the nasal cavity?
frontal, ethmoidal, maxillary, and sphenoid
Function of the frontal, ethmoidal, maxillary, and sphenoid sinuses?
serve as resonators of the voice
Sinus that is superior to the eyes and front gona, which forms the hard part of the forehead?
frontal
Nasal sinus that is between the nose and eyes?
ethmoidal
Nasal sinus that is in the center of the skull base under the pituitary?
sphenoid
Nasal sinus that is under the eyes?
maxillary
Part of nose that is especially susceptible to facial trauma?
4 paired sinuses
4 parts of upper airway?
nose, mouth, pharynx, and larynx
Separates oropharynx by imaginary plane that extends posteriorly?
nasopharynx
Separates the oropharynx from the laryngopharynx?
epiglottis
Another name of the laryngopharynx?
hypopharynx
3 parts of the pharynx?
nasopharynx, oropharynx, and hypopharynx/laryngopharynx
4 functions of pharynx?
passage for air, food, voice modulator, and equalizes pressures that are built near ear drums
What is the structure of the pharynx like?
soft, it easily collapses
Sensory and motor (4) nerve supply to the airway?
trigeminal, facial, glossopharyngeal, and vagus
Cranial nerve which is divided in to 3 parts?
trigeminal nerve
Cranial nerve IX?
glossopharyngeal
Which branch of the vagus nerve divides in to internal and external?
superior laryngeal nerve
Unilateral damage to this branch of the vagus nerve causes ipsilateral vocal cord to remain midline during inspiration, resulting in hoarseness?
RLN
Bilateral injury to this branch of CNX causes dysfunction of both vocal cords and respiratory distress/emergency?
RLN
Very vascular organ, which can cause serious bleeding issues with tonsillectomies?
palatine tonsils
3 arteries which are in palatine tonsils?
external carotid, maxillary, and facial arteries
Function of palatine tonsils?
part of lymphatic system
If these are enlarged, which often happens in children, they can pose serious airway problems? Why would they be enlarged?
palatine tonsils; infection
This structure isolates the esophagus from trachea when swallowing?
epiglottis
Which nerves (3) mediate reflexes of the epiglottis?
SLN, RLN, glossopharyngeal
Epiglottis part of which upper airway structure?
laryngopharynx
3 benefits of cuffed tube in children?
decreases fire risk, decreases waste anesthetic gasses contaminating air, decreases aspiration risk
In children size down how much in comparison to noncuffed tube?
1/2 size
How much air leak do you want around the cuff when the cuff is down in a child?
20-25 mm
This structure forms the connection of the oropharynx to the trachea?
larynx
This structure functions as protection from foreign bodies, builds up subglottic air pressure to produce cough, give birth or excrete waste, swallows, and monitors and controls air in and out of lungs to control for phonation, and allows airflow
larynx
Narrowest part of larynx in children
cricoid
Narrowest part of larynx in children >8?
vocal cords
Landmark for larynx in children
C3-C5 (anterior and cephalad)
Landmark for larynx in adults?
C4-C6
Shape of larynx in children
funnel
Shape of larynx in those >8?
cylinder
Shape of epiglottis in those
long/narrow/floppy
Shape of epiglottis in those >8?
short/wide
Direction of vocal cords in those
angled
Direction of vocal cords in those >8?
perpendicular
Strength of cartilage in children
soft and pliable
Strength of cartilage in children >8?
rigid
What is the significance of the soft and pliable cartilage in children
it easily undergoes edematous change with trauma and inflammation which can lead to obstruction
Bone that makes up larynx?
hyoid
3 paired cartilages of larynx?
arytenoid, cuneiform, corniculate
3 unpaired cartilages of larynx?
thyroid, epiglottis, and cricoid
Provides structural support for larynx?
hyoid bone
How many cartilages make up the larynx?
9
Small, U shaped bone that joins larynx and tongue?
hyoid bone
Cartilages that shield and protect vocal cords?
thyroid, paired (arytenoid, cuneiform, corniculate)
Largest cartilage in larynx?
thyroid
This branch of the vagus nerve provides sensory innervation of the laryngeal mucosa above the vocal cords (inferior epiglottis)
internal laryngeal
This branch of the vagus nerve provides motor nerve innervation for all intrinsic muscles except the cricothyroid?
recurrent laryngeal
This branch of the vagus nerve provides motor nerve innervation for the cricothyroid muscles?
external laryngeal
This branch of the vagus nerve provides sensory innervation for the laryngeal mucosa below the vocal cords?
recurrent
Branch of the vagus nerve that is responsible for laryngospasm/glottic closure?
internal branch of SLN
Branch of the vagus nerve that innervates cricothyroids, which adduct and tense the true vocal cords?
external branch of SLN
This branch of the vagus nerve is responsible for laryngospasm?
external branch of SLN
What shape are the cartilages of the trachea?
U-shape
What spinal level is the cricoid?
C-6
The first complete tracheal ring is?
cricoid
What spinal level is the carina?
T-5
Distance from carina to incisors?
26 cm
Restricted use of what 2 things for ENT procedures?
muscle relaxants and N2O
Evidence of upper airway obstruction is early or late sign?
late
You should avoid use of N2O for what 3 procedures?
ear, laser, foreign body
Do you need to decrease FiO2 flows for ENT?
yes to
What do you need to do with O2 flows for bronchs or obstruction?
increase them bc losing O2 thru bronch
4 signs of air leak/ETT cuff issue?
decreased SaO2, increased PIP, decreased ETCO2, vent bellows not rising
What consideration about the size of an ETT may be used for ENT surgeries?
smaller ETT
Where is the head of the table for ENT procedures?
turned 90-180 degrees
What should you do to the circuit for 180 degree turns?
get long one
3 things NIM-EMG monitoring measures?
facial nerve function, RLN function, vocal cord ftn
What can you do to the HOB to minimize blood loss?
slight head up
2 parameters to go by for deliberate hypotension?
keep MAP> 60, decrease starting BP by 20%
What is done for vascular tumor surgeries that are projected to be long and why?
deliberate hypotension to minimize blood loss
Type of ETT for tonsil and adenoidectomy? Where do you tape it?
right angled ETT (RAE)/90 degrees right angle tube. tape in middle of mouth
What type of tube should be used for procedures where neck flexion is needed? And what are examples of those types of surgeries?
armored tube imbedded with coiled wire; base of skull or posterior aspect of neck
What type of tubes do you use for laser surgery?
metal impregnated and fille cuff with dye or saline
Type of airway used in spontaneously breathing pt?
LMA
Type of airway used for surgeries involving pharyngeal pathology?
LMA
Type of airway used when need to visualize vocal cords and their function?
LMA
Why is there a high incidence of N/V for ENT surgeries and what do you do to prevent it?
swallow some blood, suction stomach with NGT/OGT
Is it recommended for ENT surgeries to be generous with IVFs to prevent N/V?
yes
Why is glycopyrrolate recommended over atropine for ENT surgeries to prevent secretions?
increases hr slightly less and doesn’t cross BBB to get sedative effects
What type of med can be given intraop to decrease laryngeal edema, reduce pain, decrease N/V, and prolong analgesic effects of local anesthetics?
corticosteroids
Systematic reviews have reported that what drug and only this drug increases postop bleeding?
ASA
2 drugs to consider giving to decrease requirement of opioids for ENT?
ketamine, acetaminophen
Max dose of lido and lido with epi?
4mg/kg plain; 7mg/kg with epi; (250-300 mg)
Most common classification of local anesthetics?
amides
Total dose of epi that can be given with LA?
200 mg/ 1.5 mcg/kg
How does cocaine work to decrease bleeding?
vasoconstriction, blocks reuptake of epi and norepi
What type of onset does lido have?
rapid
What type of duration does benzocaine have and what side effect?
short; methemoglobinemia
Some specifics about myringotomy and tube placement surgery?
mask induction, no IV, have anectine (suxxs) and atropine (IM) ready, children with RTIs prone to laryngospasm, short procedure
Pathophysiology as a result of long standing tonsil and adenoid issues that lead to nasal and pharyngeal upper airway obstruction?
long standing hypoexmia and hypercarbia–> increased airway resistance –> pulmonary arteriolar venule constriction–> pulmonary artery HTN–> right sided heart failure –> cor pulmonale
Indications for this surgery are recurrent acute tonsillitis, peritonsillar abscess, tonsillar hyperplasia, and OSA?
tonsillectomy and adenoidectomy/uvuloplasty
Evaluate size of what to determine ease of mask ventilation and tracheal intubation?
tonsillar size
This increases the risk of post op bleeding and laryngospasm?
URI
2 types of airways used for T&A/uvuloplasty?
cuffed RAE, reinforced LMA
Throat pack placed for which surgery?
T&A
Tonsil position is?
placed on side post op for drainage of residual oozing
Some considerations for T&A/uvuloplasty?
position-shoulder roll, head extended, table turned 90-180 degrees, throat pack and mouth gag, quick and smooth emergence, general vs inhalation induction
Should you do controlled or spontaneous ventilation for a T&A?
depends, can do either
Advantages and disadvantages for controlled vent during T&A, uvuloplasty?
guarantee immobility during surgery, need to reverse MR-N/V, residual muscle blocakde, unable to gauge titration of post op analgesia
Advantages and disadvantages of spontaneous breathing during T&A/uvuloplasty?
use RR and ETCO2 to titrate opioid to achieve smoother emergence, theoretically faster emergence because no need to wait for return of spontaneous respirations; may require deeper level of anesthesia to prevent movement, may not be option if paralysis was necessary on induction
Treatment for laryngospasm?
positive pressure (decrease pop off valve, increase positive pressure and hold), Larsen maneuver, IV Lido, Suxxs if sats dropping
Complications of T&A/uvuloplasty?
laryngospasm, bleeding tonsil
Most common pediatric emergency?
bleeding tonsil
S/S bleeding tonsil?
decrease BP, increased RR, pallor, increased HR
What should you do with induction drugs if bleeding tonsil?
decrease dose
How should bleeding tonsil pt be extubated?
fully awake
Airway for cleft palate repair?
oral RAE
What is used to hold ETT and mouth open for cleft palate/lip repair?
mouth gag
If need a non advanced airway on cleft palate repair, what do you use?
nasal airway
Why is a laryngospasm common post op for cleft palate repair?
copious secretions
Age group for acute epiglottitis?
2-7
What causes epiglottitis?
Haemophilus influenza type B
S/s epiglottitis?
drooling, sitting position with head extended and leaning forward, sudden onset fever, dysphagia, drooling, thick muffled voice, retractions, labored breathing, cyanosis
Epiglottitis can quickly progress to what?
upper airway obstruction
What type of induction for epiglottitis?
inhalation induction while sitting up
Avoid what 2 things for induction of epiglottitis?
DL, N20
How should one do epiglottitis induction?
inhalation induction sitting up, keep spontaneous vent on 100% FiO2, insert IV, insert ETT smaller by 1 size
Why are increased allergies in sinus and nasal surgery important?
can lead to possible reactive airways
Why are those with sinus and nasal surgery prone to OSA?
redundant tissue
What type of ETT do you use for general surgery in sinus and nasal surgery?
oral RAE
Where do you tape oral RAE for sinus and nasal surgery?
opposite side of surgical site
Why is local anesthesia used for sinus and nasal surgery?
increased bleeding/highly vascular area
Why would you use TIVA for endo procedures?
gas won’t get to them if not ventilating
4 complications of endoscopy procedures?
eye trauma, epistaxis, laryngospasm, bronchospasm
Anesthetic considerations for endoscopy procedures?
TIVA, MR, smaller ETT, minimize secretions, relaxed mandible, protect the teeth
Signs of this are coughing, tachycardia, aphonia, cyanosis, wheezing?
foreign body aspiration
How do you retrieve a foreign body at the level of larynx?
DLV and use Magill forceps
How do you retrieve a foreign body that is distal to the larynx or trachea?
rigid bronch
Preferred induction technique for foreign body aspiration retrieval?
gentle mask induction without cricoid or positive pressure and pt sitting up, keep spontaneously breathing
Some helpful meds to give with foreign body aspiration induction?
antisisalagogue, H2 blocker, metoclopramide
What can you do to compensate for leak with foreign body aspiration?
increase FGF, large TV, 100% FiO2
What should you prevent the pt from doing during bronch for a foreign body aspiration?
bucking, coughing
Anesthesia best to use for foreign body aspiration?
TIVA
What can extreme neck extension cause?
bradycardia
What 3 meds can help with foreign body aspiration?
steroid, inhaled racemic epi, bronchidilators
Edema can persist for how many hours post removal of object from airway?
24 hours
To check for airway edema, you should listen to air movement around ETT for how many breaths during inspiration and expiration?
2
Nerve isolation can be accomplished with what 2 things for procedures of the face and ear?
brainstem auditory evoked potentials and EMG monitoring
What does radiation to the neck do to the tissues?
makes them soft and less mobile so more difficult intubation
Usual size Shiley for male and female?
8 and 6
Why do you have to watch the fluid intake for radical neck procedures?
can cause congestion and edema to flap which would cause vascular compromise
What’s another complication you have to be on the look out for during radical neck procedures and why?
venous embolism bc HOB up and sometimes neck veins exposed
Something you can do to decrease the risk of venous air embolism in radical neck patient?
positive pressure ventilation
Which nerve is commonly damaged in radical neck procedure?
RLN
What cardiac issue can be caused by radical neck dissection?
QT prolongation
What’s a potential complication with low neck dissection?
pneumothorax
Stimulation of this during radical neck dissection can elicit the vagal response?
carotid sinus
What may cause high anesthesia circuit pressure in radical neck surgery?
if surgeon retracting the trachea too much
3 signs that NGT insertion could go in to brain?
CSF in nose, blood behind the tympanic membrane, and periorbital edema/racoon eyes
Le Fort fracture that is triangular and runs thru bridge of nose thru medial and inferior wall of orbit?
Le Fort II
What should you avoid with ventilation when have Le Fort II or III fracture?
+ pressure ventilation
Le Fort fracture that is a horizontal fracture of the maxilla extending from the floor of the nose to the hard palate thru nasal septum?
I
Le Fort fracture where have total separation of the mid facial skeleton from cranial face transverse root of nose, F1 bone, and in to eye orbits?
III
Patients with facial trauma should be thought to have what until proven otherwise?
cervical injury
Intermaxillary fixation has what implications for CRNA?
always have wire cutters!!
Do you need an ETT for jet ventilation?
no
4 types of patients where jet ventilation should be avoided?
full stomach, hiatal hernia, trauma, pregnancy
An ENT surgery jet vent might be used for because it allows direct view of larynx, immobility of cords, and complete control of airway?
diagnostic laryngoscopy
How could you use jet ventilation in emergency situation?
placement of needle thru cricothyroid membrane
Type of HFJV where jet pipe is situated above the vocal cords and usually connected to the surgeon’s laryngoscope?
supraglottic, endopharyngeal
Type of HFJV where oxygen jet is blown in to trachea distally to vocal cords or stenotic area?
infraglottic, intratracheal
What kind of device blows oxygen for HFJV infraglottic/intratracheal?
rigid bronchoscope
What can help facilitate exhalation with HFJV?
OA or NA
What type of exhalation is HFJV?
passive
During HFJV, O2 is delivered under pressure thru a what gauge catheter attached to O2 source?
14-16
What type of flow is HFJV?
intermittent
The index safety system for HFJV?
DISS
An obstruction to passive exhalation?
excessively large TV
> __ PSI can cause barotrauma in HFJV?
50
What type of TV and RR are used with HFJV?
low TV, high RR
Inspiration of HFJV is up to __ PSI?
60
HFJV is on for __ sec and off for __ sec?
1;2
3 things that can happen if jet stream is not accurately aimed in HFJV?
barotrauma, SQ emphysema, gastric distension
Patients with decreased lung compliance-obese, COPD, bronchospasm are at risk for what during HFJV?
hypoventilation
What type of anesthesia must be used for HFJV?
TIVA
What do you ask the surgeon about at the end of HFJV procedure?
vocal cord movement
Laser stands for?
light amplification by stimulated emission of radiation
2 qualities of laser light?
moves in one direction and is one wavelength
3 functions of lasers?
cut, coagulate, vaporize
The 3 components of a laser?
laser medium, laser/optical cavity, pump source
Component of laser which enhances the efficacy of the laser by providing feedback (mirrors)
optical cavity
Component of laser which contains the atoms used to create the laser light (solid, liquid, or GAS)?
laser medium
Component of laser which provides the external energy source that raises the energy of the atoms enough to produce laser light?
pump source
Component of the laser that determines wavelength?
laser medium
The amplifying medium of a laser is usually?
gas
Wavelength or color of laser depends on what?
laser medium (gas)
The effect the laser has on tissue depends on?
wavelength
Type of laser which is visible blue green light and main effect is photocoagulation?
argon-gas
Type of laser which is green light and used to cut tissue and remove vascular lesions?
KTP-gas
Most widely used laser?
CO2
This laser produces infrared light undetected by the human eye?
CO2
What type of wavelength is produced by CO2 laser and what does that mean for surrounding tissues?
long; absorbed almost entirely by the surface of the tissue
Benefit and disadvantage of CO2 laser?
very precise; can cause corneal injury
Laser mostly used in otolaryngology surgery?
CO2
Type of laser that is shorter wavelength?
Nd-YAG
Nd-YAG used commonly in which 2 type of procedures?
ENT, opthalmology
Shorter wavelength with Nd-YAG allows for what type of penetration?
deeper
What do you have to be careful about with the Nd-YAG laser?
it can burn the retina
Lasers which produce the most and least smoke?
CO2; Nd-YAG
2 ways to eliminate atmospheric contamination of toxic fumes?
smoke evacuator and special masks
Color glasses for CO2, Nd: YAG, and argon, KTP lasers?
clear for CO2; green for Nd: YAG; argon and KTP are amber orange
