ENT Modified Flashcards
1
Q
Trigeminal Nerve
A
CN V
Sensory and Motor
Ophthalmic, Maxillary, mandibular
2
Q
Glossopharyngeal Nerve
A
CN 9 sensory Posterior 1/3 of tongue oropharynx anterior of epiglottis vallecula
3
Q
Facial Nerve
A
CN 7 both 6 branches: anterior: temporal zygomatic buccal mandibular inferior: cervical posterior: posterior auricle
4
Q
Vagus Nerve
A
Both
CNX
Superior laryngeal nerve
Recurrent laryngeal nerve
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
6
Q
Recurrent Laryngeal Nerve
A
Internal: sensory innervation to below vocal cords and trachea
Motor: all intrinsic muscles below the larynx
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
8
Q
What does sharing the airway require?
A
preparation
planning
communication
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
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
11
Q
Special considerations for ENT surgery
A
vasoactive drugs anticholinergics corticosteroids postoperative nausea and vomiting deliberate controlled hypotension
12
Q
Epinephrine in ENT causes
A
vasoconstriction
1:200,000 5mg/ml
epinephrine 1:100,000 (10mcg/ml)
1:50,000 (20mcg/ml)
13
Q
Cocaine in ENT cases
A
naturally occurring ester of benzoic acid that provides vasoconstriction and analgesia
14
Q
Combination of epi and cocaine can result in
A
headaches, HTN, tachycardia, dysrhythmias
15
Q
Local anesthetics (3)
A
cocaine (4%)
lidocaine (2%,4%, 10%)
bupivacaine (0.25%,0.5%, 0.75%)
16
Q
What is the purpose of anticholinergics?
A
antisialague effects
reduced vagal tone
Not for closed angle glaucoma
17
Q
What is the purpose of glucorticoids?
A
reduce nausea and vomiting (give early)
inhibit production of prostaglandins reducing pain, edema
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
19
Q
How do you achieve deliberate controlled hypotension?
A
beta blockade, propofol infusions (TIVA), remifentanil 0.05-0.2mcg/kg/min
20
Q
Advantages of nitroprusside for hypotension
A
potent reliable, rapid onset
21
Q
Dose of nitroprusside for hypotension
A
1-8mcg/kg/min
22
Q
Disadvantages of nitroprusside for hypotension
A
reflex tachycardia and rebound HTN
23
Q
Dose of Nitroglycerin for hypotension
A
125-500mcg/kg/min
Children: 10-15mcg/kg/min
24
Q
Advantages of nitroglycerin for hypotension
A
preserve myocardial blood flow
25
Disadvantages of nitroglycerin for hypotension
variable dosing
26
What is the dose of nicardapine for hypotension?
5mcg/kg/min
27
What are the advantages of nicardipine for hypotension
preserves cerebral blood flow
28
What are common techniques used in ENT surgery?
laser surgery
endoscopy
jet ventilation
29
What are common lasers in ENT
co2
Nd: YAG
Argon
30
Describe a CO2 laser
(longer wavelength, shallow depth and precise)
31
Describe a nd: YAG laser
shorter wavelength, passes through superficial structures
32
How can the laser light be?
monochromatic (one wave-length)
coherent
collimated
33
What are the keys to laser safety?
warning signs outside the OR
eye protection
Prevention of airway fires
34
How do you prevent airway fires?
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
35
What is the fire triad?
oxidizer
ignition source
fuel
36
What needs to happen if there is an airway fire?
remove ETT immediately and replace with new tube
| bronchoscopy and evaluate airway
37
Considerations for endoscopy (3)
manage brief periods of extreme stimulation (no movement)
short procedures
constantly sharing airway with surgeon
38
How can you manage brief periods of extreme stimulation?
consider lidocaine, remifentanil, esmolol to block sympathetic stimulation
39
What do have to be aware of with short procedures?
NMR
40
What are considerations for sharing the airway with the surgeon?
small, cuffed ETT 5-6 for adult
| intermittent apnea
41
What is jet ventilation?
manual ventilation using hand valve or mechanical device
inspiration is high velocity jet stream (60psi)
expiration is passive
42
What happens if jet ventilating and airway mass is above level of gas delivery
increased risk of air trapping resulting in subcutaneous emphysema or pneumothorax
43
What are other considerations for jet ventilation?
TIVA
| TCO2
44
When is TJV contraindicated?
Full stomach
hiatal hernia
trauma
45
When is high frequency jet ventilation used?
limited access to the airway
46
How is high frequency jet ventilation performed?
done through small needle, ETT, catheter or side port to a rigid bronchoscopy
47
what does high frequency jet ventilation provide
low tidal volumes and high respiratory rates
48
What nerves are most commonly monitored ?
facial, recurrent and inferior laryngeal nerves, vagus nerve, spinal accessory nerve
49
What are alternatives to prevent patient movement?
remifentanil 0.05-0.2mcg/kg/min
TIVA
Nitrous Oxide
50
BMT Bilateral Myringotomy and Tympanostomy
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
What does a BMT do?
alleviates pressure from middle ear and serves as stent allowing continued drainage until the tubes are naturally extruded in 6months to 1 year
52
What can chronic media lead to?
hearing loss and formation of cholesteatoma
53
What is recurrent otitis media?
three or more acute infection in a six month periof
| 4 in a one year period
54
Anesthetic considerations for BMT
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
What is the middle ear?
refers to the air filled space between the tympanic membrane and oval window
56
What are common middle ear surgeries?
tympanoplasty
stapedectomy or ossiculoplasty
mastoidectomy
cochlear implants
57
Surgical considerations for middle ear
```
congenital defects
trauma
treatment of disease
bloodless field
microsurgery
```
58
Anesthesia considerations for middle ear
no nitrous oxide and muscle relaxants if nerve monitoring
local anesthesia: ability to test hearing during surgery
PONV common
controlled hypotension
deep extubation
59
What is an indication for a tympanoplasty?
perforated eardrum
60
What are the two approaches for tympanoplasty?
```
post auricular (posterior auditory canal)
Temporal fascial graft (ossicular chain abnormalities repaired with prothesis)
```
61
What are mastoid cells?
cells that are open to air
62
What are indications for a mastoidectomy
cholesteatoma
| mastoiditis
63
What is the approach to a mastoidectomy?
entry through the post auricular region
64
What are anesthetic considerations for a mastoidectomy
no nitrous oxide or muscle relaxation
65
cholesteatomas
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
what is a septoplasty?
correct derformities of nasal septum
67
What is a rhinoplasty?
repair or re-shaping of the nose
cosmetic
airway restoration
68
What are indications for sinus surgery?
```
sinus obstruction (infection, polyps, tumors)
sinusotomies
```
69
What are surgical options for sinus surgery?
endoscopic
External
fluroscopy
brain lab
70
In sinus surgery what are polyps associated with?
asthma and cystic fibrosis
reactive airway
allergies
no nsaids
71
What are strategies to decrease bleeding in sinus surgery?
```
mild hypotension (Deep anesthesia or antihypertensive)
vasoconstrictor use
```
72
What are complications to sinus surgery?
dural puncture
73
How do you treat a dural puncture?
```
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
Where can clefts occur?
one or more different places on the face, such as lips, the palate, or the gum ridge (alveolus)
75
What are signs and symptoms of cleft palate?
difficulty feeding, malnutrition, speech development, congenital heart defects
76
What tube is needed for cleft palates?
oral RAE with flexible connector
77
What are anesthetic considerations for cleft palates?
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
S/S of foreign body aspiration
wheezing
coughing
aphonia
cyanosis
79
What determines the FB lodgement?
size and shape if ends in larynx, trachea, bronchial, gastrointestinal system
80
How is a FB removed from the larynx?
laryngoscopy and removal of magill forceps
81
How is a FB removed from distal larynx or trachea?
rigid bronchoscopy
(mouth guard avoids injury)
tracheal tears, inadequate ventilation
82
In a FB xray, how do the xray look?
if in lung, hypodense (darker lung) because air does not escape
83
Perioperative management of FB
```
NPO
administer oxygen if respiratory distress
experienced ENT/OHN and anesthesia team
corticosteroids
PIV
Avoid coughing and agitation
```
84
What is a rigid bronchoscope?
```
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
Describe the anesthesia technique for distal larynx or trachea
inhalation induction
maintain spontaneous respiration
turn bed
Full stomach (RSI) be prepared for full airway obstruction
86
Who needs to be in the room for induction of distal larynx/trachea FB?
all team members in room
87
Postoperative distal larynx/trachea FB
may intubate the trachea to provide ventilation during emergence
edema may occur for next 24 hours
88
What is the most common indication for T&A in america?
OSA
89
Are are the surgical methods of tonsillectomy?
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
Intraoperative T&A
```
standard induction
Oral RAE (cuffed with 2cmH20)/ LMA-- secure midline
table turned 45/90 degrees
mouth gag
analgesia management
```
91
Anesthesia implications for a mouth gag
requires adequate depth of anesthesia
re-evaluate airway after placement to ensure no dislodgement of ETT or LMA
throat pack
92
Analgesia management for T&A
increase dose of dexamethasone (0.5-1mg/kg)
zofran 0.1mg/kg
dex at 0.1-0.5mcg/kg IV
93
What should be avoided in T&A
codeine d/t its metabolism varies in children and cause respiratory distress
94
For T&A emergence why should you be cautious administering opioids?
a restless child may be indicative of airway compromise or hypoxia
95
Describe anesthetic considerations for the bleeding tonsil
```
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
What is the largest endocrine gland in the body?
thyroid
97
What two nerve course along lateral lobes of thyroid?
RLN and External branch of SLN
98
What are preoperative anesthetic considerations for thyroid surgery?
euthyroid
| thyroid and beta blocker
99
What are regional anesthetic considerations for thyroid surgery?
combined deep and superifical cervical plexus block
100
What vasopressor is best?
phenylephrine
101
What position is best for thyroid surgery?
```
rose position
eye protection (googles, padding)
```
102
Where is your NIMBs tube placed?
electrodes contact right and left vocal cords
103
What are postoperative considerations for thyroid surgery?
```
hypocalcemia (perioral numbness and tingling), tetany, chvostek sign, laryngospasm, QT prolongations, mental status chagnes and seizures
RLN damage (unilateral >bilateral)
hematoma
```
104
What are signs of bilateral RLN injury?
biphasic stridor
dyspnea
respiratory distress
aphonia
105
What are anesthetic considerations for dental surgery?
```
standard indution
nasal intubation (oxymethazoline spray, warmed RAE, nasal trumpet dilation, red rubber catheter)
throat pack
OG suction
deep extubation
```
106
How can you intubate with severe face or neck trauma?
retrograde intubation
jet ventilation via cricothyrotomy
emergent tracheostomy
107
What is a leforte 1 fracture?
horizontal fracture extending from the floor to of the nose and hard palate through the nasal septum
108
Leforte 2
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
Leforte 3
separates the midfacial skeleton from the cranial base, transversing the root of the nose, ethmoid bone, eye orbits and sphenopalatine fossa
110
Anesthetic considerations for trauma ENT
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
Anesthetic considerations for radical neck dissection
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
Postoperative anesthesia considerations for radical neck dissection
```
trach care
controlled ventilation
chest radiography
monitor for laryngeal edema
ICU for potential edema, fluid shifts, altered ventilation, extensive anesthesia time
```
