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N931 Advanced Principles > ENT Modified > Flashcards

ENT Modified Flashcards

1
Q

Trigeminal Nerve

A

CN V
Sensory and Motor
Ophthalmic, Maxillary, mandibular

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2
Q

Glossopharyngeal Nerve

A 
CN 9
sensory
Posterior 1/3 of tongue
oropharynx
anterior of epiglottis
vallecula
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3
Q

Facial Nerve

A 
CN 7 both
6 branches:
anterior: temporal zygomatic buccal mandibular
inferior: cervical
posterior: posterior auricle
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4
Q

Vagus Nerve

A

Both
CNX
Superior laryngeal nerve
Recurrent laryngeal nerve

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5
Q

Superior laryngeal nerve

A

Internal branch: sensory innervation to the vocal cord folds and posterior epiglottis
Motor: motor innervation below the vocal cords

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6
Q

Recurrent Laryngeal Nerve

A

Internal: sensory innervation to below vocal cords and trachea
Motor: all intrinsic muscles below the larynx

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7
Q

What is considered critical in your ENT pre-operative assessment

A

thorough history and extensive evaluation
-deliberate approach to airway management
need for additional equipment and assistance
determine need for alternative approaches
anticipation and approach of the difficult airway

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8
Q

What does sharing the airway require?

A

preparation
planning
communication

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9
Q

Common Considerations for ENT surgery (10)

A 
Bed turned 90/180
True sharing of airway with surgeon
Precordial or esophageal stethoscope
Management of extreme stimulation
prevention of airway fires
nerve monitoring
prevent extubation, disconnects, and leaks
ALWAYS reassess patient after turning
Management of intraoperative blood loss
prevention of postoperative airway obstruction
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10
Q

What are some specialized equipment for ENT surgery?

A

small diameter ETT (decreased ventilation and increased resistance)
standard tubes may result limited cuff contact
Oral and nasal RAE tubes
Armored and reinforced tubes (resist kinking)
metal-impregnanted (reduce airway fire)
LMA

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11
Q

Special considerations for ENT surgery

A 
vasoactive drugs
anticholinergics
corticosteroids
postoperative nausea and vomiting
deliberate controlled hypotension
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12
Q

Epinephrine in ENT causes

A

vasoconstriction
1:200,000 5mg/ml
epinephrine 1:100,000 (10mcg/ml)
1:50,000 (20mcg/ml)

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13
Q

Cocaine in ENT cases

A

naturally occurring ester of benzoic acid that provides vasoconstriction and analgesia

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14
Q

Combination of epi and cocaine can result in

A

headaches, HTN, tachycardia, dysrhythmias

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15
Q

Local anesthetics (3)

A

cocaine (4%)
lidocaine (2%,4%, 10%)
bupivacaine (0.25%,0.5%, 0.75%)

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16
Q

What is the purpose of anticholinergics?

A

antisialague effects
reduced vagal tone
Not for closed angle glaucoma

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17
Q

What is the purpose of glucorticoids?

A

reduce nausea and vomiting (give early)

inhibit production of prostaglandins reducing pain, edema

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18
Q

Why use deliberate controlled hypotension in ENT cases?

A

reduces blood loss in prolonged cases
reduce MAP to pre-determined limits of cerebral autoregulation (50-60mmHg) 10-20% of baseline
arterial line prudent

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19
Q

How do you achieve deliberate controlled hypotension?

A

beta blockade, propofol infusions (TIVA), remifentanil 0.05-0.2mcg/kg/min

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20
Q

Advantages of nitroprusside for hypotension

A

potent reliable, rapid onset

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21
Q

Dose of nitroprusside for hypotension

A

1-8mcg/kg/min

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22
Q

Disadvantages of nitroprusside for hypotension

A

reflex tachycardia and rebound HTN

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23
Q

Dose of Nitroglycerin for hypotension

A

125-500mcg/kg/min

Children: 10-15mcg/kg/min

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24
Q

Advantages of nitroglycerin for hypotension

A

preserve myocardial blood flow

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25
Q

Disadvantages of nitroglycerin for hypotension

A

variable dosing

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26
Q

What is the dose of nicardapine for hypotension?

A

5mcg/kg/min

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27
Q

What are the advantages of nicardipine for hypotension

A

preserves cerebral blood flow

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28
Q

What are common techniques used in ENT surgery?

A

laser surgery
endoscopy
jet ventilation

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29
Q

What are common lasers in ENT

A

co2
Nd: YAG
Argon

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30
Q

Describe a CO2 laser

A

(longer wavelength, shallow depth and precise)

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31
Q

Describe a nd: YAG laser

A

shorter wavelength, passes through superficial structures

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32
Q

How can the laser light be?

A

monochromatic (one wave-length)
coherent
collimated

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33
Q

What are the keys to laser safety?

A

warning signs outside the OR
eye protection
Prevention of airway fires

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34
Q

How do you prevent airway fires?

A

use lowest O2 concentration possible (goal <30%)
avoid nitrous oxide
fill ET with saline/methylene blue
laser “plume” should be suctioned from surgical field
avoid paper drapes
use water based lubricants
metal impregnanted ETT

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35
Q

What is the fire triad?

A

oxidizer
ignition source
fuel

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36
Q

What needs to happen if there is an airway fire?

A

remove ETT immediately and replace with new tube

bronchoscopy and evaluate airway

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37
Q

Considerations for endoscopy (3)

A

manage brief periods of extreme stimulation (no movement)
short procedures
constantly sharing airway with surgeon

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38
Q

How can you manage brief periods of extreme stimulation?

A

consider lidocaine, remifentanil, esmolol to block sympathetic stimulation

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39
Q

What do have to be aware of with short procedures?

A

NMR

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40
Q

What are considerations for sharing the airway with the surgeon?

A

small, cuffed ETT 5-6 for adult

intermittent apnea

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41
Q

What is jet ventilation?

A

manual ventilation using hand valve or mechanical device
inspiration is high velocity jet stream (60psi)
expiration is passive

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42
Q

What happens if jet ventilating and airway mass is above level of gas delivery

A

increased risk of air trapping resulting in subcutaneous emphysema or pneumothorax

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43
Q

What are other considerations for jet ventilation?

A

TIVA

TCO2

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44
Q

When is TJV contraindicated?

A

Full stomach
hiatal hernia
trauma

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45
Q

When is high frequency jet ventilation used?

A

limited access to the airway

46
Q

How is high frequency jet ventilation performed?

A

done through small needle, ETT, catheter or side port to a rigid bronchoscopy

47
Q

what does high frequency jet ventilation provide

A

low tidal volumes and high respiratory rates

48
Q

What nerves are most commonly monitored ?

A

facial, recurrent and inferior laryngeal nerves, vagus nerve, spinal accessory nerve

49
Q

What are alternatives to prevent patient movement?

A

remifentanil 0.05-0.2mcg/kg/min
TIVA
Nitrous Oxide

50
Q

BMT Bilateral Myringotomy and Tympanostomy

A

creates an opening in the tympanic membrane through which fluid can drain
placement of ventilation tube (tympanostomy) with a lumen is frequently also performed

51
Q

What does a BMT do?

A

alleviates pressure from middle ear and serves as stent allowing continued drainage until the tubes are naturally extruded in 6months to 1 year

52
Q

What can chronic media lead to?

A

hearing loss and formation of cholesteatoma

53
Q

What is recurrent otitis media?

A

three or more acute infection in a six month periof

4 in a one year period

54
Q

Anesthetic considerations for BMT

A

short operations (watch oral sedatives may outlast procedure)
mask induction
antibiotics and steroids placed in ear
mild pain medications given orally or rectally
often mask anesthetic only
(IV placed if other procedure being completed)

55
Q

What is the middle ear?

A

refers to the air filled space between the tympanic membrane and oval window

56
Q

What are common middle ear surgeries?

A

tympanoplasty
stapedectomy or ossiculoplasty
mastoidectomy
cochlear implants

57
Q

Surgical considerations for middle ear

A 
congenital defects
trauma
treatment of disease
bloodless field
microsurgery
58
Q

Anesthesia considerations for middle ear

A

no nitrous oxide and muscle relaxants if nerve monitoring
local anesthesia: ability to test hearing during surgery
PONV common
controlled hypotension
deep extubation

59
Q

What is an indication for a tympanoplasty?

A

perforated eardrum

60
Q

What are the two approaches for tympanoplasty?

A 
post auricular (posterior auditory canal)
Temporal fascial graft (ossicular chain abnormalities repaired with prothesis)
61
Q

What are mastoid cells?

A

cells that are open to air

62
Q

What are indications for a mastoidectomy

A

cholesteatoma

mastoiditis

63
Q

What is the approach to a mastoidectomy?

A

entry through the post auricular region

64
Q

What are anesthetic considerations for a mastoidectomy

A

no nitrous oxide or muscle relaxation

65
Q

cholesteatomas

A

destructive and expanding growth consisting of keratinizing squamous epithelium in the middle ear and/or mastoid process.
result in the destruction of the bones of the middle ear, as well as growth through the base of the skull into the brain. They often become infected and can result in chronically draining ears

66
Q

what is a septoplasty?

A

correct derformities of nasal septum

67
Q

What is a rhinoplasty?

A

repair or re-shaping of the nose
cosmetic
airway restoration

68
Q

What are indications for sinus surgery?

A 
sinus obstruction (infection, polyps, tumors)
sinusotomies
69
Q

What are surgical options for sinus surgery?

A

endoscopic
External
fluroscopy
brain lab

70
Q

In sinus surgery what are polyps associated with?

A

asthma and cystic fibrosis
reactive airway
allergies
no nsaids

71
Q

What are strategies to decrease bleeding in sinus surgery?

A 
mild hypotension (Deep anesthesia or antihypertensive)
vasoconstrictor use
72
Q

What are complications to sinus surgery?

A

dural puncture

73
Q

How do you treat a dural puncture?

A 
discontinue nitrous oxide
ET 25-30mmHg
mild hypotension
consider mannitol 25-50gm IV (place foley)
patch by surgeon
deep extubation (do not want to cough)
74
Q

Where can clefts occur?

A

one or more different places on the face, such as lips, the palate, or the gum ridge (alveolus)

75
Q

What are signs and symptoms of cleft palate?

A

difficulty feeding, malnutrition, speech development, congenital heart defects

76
Q

What tube is needed for cleft palates?

A

oral RAE with flexible connector

77
Q

What are anesthetic considerations for cleft palates?

A

airway can be difficult
mouth gag (reassess breath sounds once positioned)
secretions and blood (clear airway before emergence) [no yanker]
possibility of airway and tongue edema
extubate once return of protective airway reflexes
protect surgical site from child’s manipulation

78
Q

S/S of foreign body aspiration

A

wheezing
coughing
aphonia
cyanosis

79
Q

What determines the FB lodgement?

A

size and shape if ends in larynx, trachea, bronchial, gastrointestinal system

80
Q

How is a FB removed from the larynx?

A

laryngoscopy and removal of magill forceps

81
Q

How is a FB removed from distal larynx or trachea?

A

rigid bronchoscopy
(mouth guard avoids injury)
tracheal tears, inadequate ventilation

82
Q

In a FB xray, how do the xray look?

A

if in lung, hypodense (darker lung) because air does not escape

83
Q

Perioperative management of FB

A 
NPO
administer oxygen if respiratory distress
experienced ENT/OHN and anesthesia team
corticosteroids
PIV
Avoid coughing and agitation
84
Q

What is a rigid bronchoscope?

A 
Gold standard
extremely stimulating
passed through vocal cords
side port for ventilation/ jet ventilation
telescopic eye piece is exchanged for optical forceps
-leak, hypoxia
Use high flows and TIVA
avoid coughing
85
Q

Describe the anesthesia technique for distal larynx or trachea

A

inhalation induction
maintain spontaneous respiration
turn bed
Full stomach (RSI) be prepared for full airway obstruction

86
Q

Who needs to be in the room for induction of distal larynx/trachea FB?

A

all team members in room

87
Q

Postoperative distal larynx/trachea FB

A

may intubate the trachea to provide ventilation during emergence
edema may occur for next 24 hours

88
Q

What is the most common indication for T&A in america?

A

OSA

89
Q

Are are the surgical methods of tonsillectomy?

A

cold steel (more pain hemorrhage)
electro-dissection (heat of cautery, pain)
microdebrider (associated with less m&M)
coblation (provides dissection, cautery, suction and hemostasis in same machine)
radio frequency
laser

90
Q

Intraoperative T&A

A 
standard induction
Oral RAE (cuffed with 2cmH20)/ LMA-- secure midline
table turned 45/90 degrees
mouth gag
analgesia management
91
Q

Anesthesia implications for a mouth gag

A

requires adequate depth of anesthesia
re-evaluate airway after placement to ensure no dislodgement of ETT or LMA
throat pack

92
Q

Analgesia management for T&A

A

increase dose of dexamethasone (0.5-1mg/kg)
zofran 0.1mg/kg
dex at 0.1-0.5mcg/kg IV

93
Q

What should be avoided in T&A

A

codeine d/t its metabolism varies in children and cause respiratory distress

94
Q

For T&A emergence why should you be cautious administering opioids?

A

a restless child may be indicative of airway compromise or hypoxia

95
Q

Describe anesthetic considerations for the bleeding tonsil

A 
ensure adequate IV access
hypovolemia- needs fluids
potential for hemodynamic instability on induction
H&H, T&C coagulation studies
considered a full stomach requires RSI
(adequate O2), propofol or ketamine followed by succinylcholind 2mg/kg IV
potential difficult airway
OG to empty stomach
96
Q

What is the largest endocrine gland in the body?

A

thyroid

97
Q

What two nerve course along lateral lobes of thyroid?

A

RLN and External branch of SLN

98
Q

What are preoperative anesthetic considerations for thyroid surgery?

A

euthyroid

thyroid and beta blocker

99
Q

What are regional anesthetic considerations for thyroid surgery?

A

combined deep and superifical cervical plexus block

100
Q

What vasopressor is best?

A

phenylephrine

101
Q

What position is best for thyroid surgery?

A 
rose position
eye protection (googles, padding)
102
Q

Where is your NIMBs tube placed?

A

electrodes contact right and left vocal cords

103
Q

What are postoperative considerations for thyroid surgery?

A 
hypocalcemia (perioral numbness and tingling), tetany, chvostek sign, laryngospasm, QT prolongations, mental status chagnes and seizures
RLN damage (unilateral >bilateral)
hematoma
104
Q

What are signs of bilateral RLN injury?

A

biphasic stridor
dyspnea
respiratory distress
aphonia

105
Q

What are anesthetic considerations for dental surgery?

A 
standard indution
nasal intubation (oxymethazoline spray, warmed RAE, nasal trumpet dilation, red rubber catheter)
throat pack
OG suction
deep extubation
106
Q

How can you intubate with severe face or neck trauma?

A

retrograde intubation
jet ventilation via cricothyrotomy
emergent tracheostomy

107
Q

What is a leforte 1 fracture?

A

horizontal fracture extending from the floor to of the nose and hard palate through the nasal septum

108
Q

Leforte 2

A

triangular fracture running from the bridge of the nose, through the medial and inferior wall of the orbit, beneath the zygoma and through the lateral wall of the maxilla

109
Q

Leforte 3

A

separates the midfacial skeleton from the cranial base, transversing the root of the nose, ethmoid bone, eye orbits and sphenopalatine fossa

110
Q

Anesthetic considerations for trauma ENT

A

avoid naso-tracheal intubation
consider other trauma (cervical, thoracic and abdominal)
correct ABCs before addressing facial trauma
anticipate extensive blood loss (T&C, deliberate hypotension if tolerated)
consider remaining intubated
awake intubation (maintain airway reflexes)
cutting tools attached to patient or available at the bedside if jaw wired

111
Q

Anesthetic considerations for radical neck dissection

A

Airway management
CT results, consult surgeon, preoperative exam
Pre-operative labs: T&C
IVs x2
arterial line (tight BP control), lab analysis
muscle paralysis
controlled hypotension
minimize vasoconstrictors (flap perfusion)
intake and output (colloid vs crystalloid)
vagal response (anticholinergic)
hyperoxygenate patient

112
Q

Postoperative anesthesia considerations for radical neck dissection

A 
trach care
controlled ventilation
chest radiography
monitor for laryngeal edema
ICU for potential edema, fluid shifts, altered ventilation, extensive anesthesia time

N931 Advanced Principles (14 decks)

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