ENT Surgeries Flashcards
four cranial nerves that supply sensory and motor function to the airway
- trigeminal (CN V)
- glossopharyngeal (CN IX)
- facial (CN VII)
- vagus (CN X)
trigeminal nerve
-provides sensory innervation to the face
three divisions of the trigeminal nerve
- opthalmic (V1)
- maxillary (V2)
- mandibular (V3)
anterior ethmoid nerve
- terminal branch of V1
- opthalmic nerve
- innervation = sensory to nares and anterior 1/3 of nasal septum
spenopalatine nerve
- branch of V2
- innervation = turbinates and posterior 2/3 of nasal septum
lingual nerve
- branch of V3
- innervation = sensory to anterior 2/3 of tongue
glossopharyngeal nerve
- provides sensory innervation to –> posterior 1/3 of the tongue, oropharynx, vallecula, anterior epiglottis
- also the afferent limb of the gag reflex
facial nerve
- located at the tragus of the ear
- supplies motor and sensory function to the face for facial expressions
branches of the facial nerve (6)
- the zebra bit my cousin paul
- temporal, zygomatic, buccal, mandibular, cervical, posterior auricular
six major branches of the facial nerve
- anterior = temporal, zygomatic, buccal, mandibular
- inferior = cervical
- posterior = posterior auricular
vagus nerve branches
- SLN
- RLN
superior laryngeal nerve
- branch of vagus nerve
- internal branch = sensory innervation to posterior epiglottis to vocal cord folds (SIS)
- external branch = motor innervation below the vocal cords (SEM)
recurrent laryngeal nerve
- sensory innervation below the vocal folds and trachea
- motor innervation to all intrinsic laryngeal muscles
- R RLN loops under subclavian
- L RLN loops under aorta (more susceptible to injury)
- both R and L ascend in tracheal-esophageal groove to join in larynx
risk factors for RLN injury
- external pressure from ETT or LMA
- injury from thyroid/parathyroid surgery
- excessive neck stretching
- neoplasm
L RLN specific risk factors for injury
- PDA ligation
- LA enlargement dt mitral valve stenosis
- aortic aneurysm surgery
- thoracic tumor resection
acute unilateral RLN injury
- affected cord assumes adducted, paramedian position
- hoarseness
bilateral RLN injury
-respiratory distress, stridor, requires EMERGENCY airway
arterial anatomy of head/face (HEENT)
- increased vascularity compared to other parts of the body
- carotid
- facial
- maxillary
- superficial temporal
- deep temporal
- superior thyroid
- buccal
- middle meningeal
veins of face, head, and neck
- deep = internal jugular, maxillary, vertebral
- superficial = external jugular, superficial temporal, occipital, facial
common ENT surgery considerations
- true sharing of the airway with the surgery
- eye protection important
- make sure tube placement allows for surgical facilitation
- head of bead often rotated 90-180 degrees (may need more tubing length)
- arms tucked = second IV, nerve monitoring on face
- may need precordial stethoscope since HOB turned away from you
- special nerve monitoring tube (?) NIMS
- prevent extubation, disconnects, and leads; ETT secured with tape or sutured
- ALWAYS reassess patient and tube position with turns
common vasoactive drugs used in ENT
- epi (1:200,000 – vasoconstriction)
- cocaine - naturally occurring ester of benzoic acid
- combo of these can lead to HA, HTN, tachycardia, and dysrhythmias
common LAs in ENT
- cocaine 4%
- lidocaine 2%
- bupivacaine 0.25%
common anticholinergics in ENT
- for antisialagogue effects
- reduction of vagal tone
- glycopyrolate preferred (0.2 mg)
common corticosteroids in ENT
- dexamethasone
- reduce N/V
- inhibit production of prostaglandins so reduce pain and edema
PONV in ENT surgery
- associated with increase incidence of PONV, espeically procedures involving the middle ear (often get vertigo and disequilibrium with this)
- also accumulation of blood in oropharynx is swallowed and can cause PONV (prevent with throat pack and orogastric suctioning prior to extubation)
- multimodal approach to prevent/treat PONV
deliberate controlled hypotension
- technique used to reduce blood loss in prolonged cases
- reduce MAP to pre-determined limits of cerebral autoregulation
- usually MAP 50-60 mmHg or within 20% of baseline
- A line required (acc to text book)
- better operating conditions achieved when hypotension is achieved with beta-blockade
laser surgery
- laser light beams used for thermal effect (have only one wavelength)
- commonly used lasers in ENT = CO2, Nd:YAG, Argon
CO2 laser
longer wavelength
shallow depth and precise
Nd:YAG
- neodymium-doped yttrium aluminum garnett
- shorter wavelength
- passes through superficial structures
laser safety
- warning signs outside of OR
- eye protection - for the provider and the patient; each laser/specific wavelength has a specific set of glasses
- use lowest oxygen concentration possible (goal <30%)
- avoid N2O
- fill ETT with saline or methylene blue
- laser plume (debris of laser)
fire triad (for airway fire)
- oxidizer = oxygen, nitrous oxide, room air
- ignition source = ESUs, lasers, fiberoptic light source
- fuel = alcohol based skin prep, surgical drape, patient
airway fire
- most occur during head and neck surgery
- combination of oxygen and laser used
- laser penetrates ETT into oxygen rich environment and creates blowtorch effect
- REMOVE ETT IMMEDIATELY and replace with new one
- bronch after
ways to prevent airway fire
- metal impregnated ETT
- saline filled ETT cuff
- use lowest FiO2 possible
- avoid N2O
- avoid paper drapes
- use water based lubricants
endoscopy procedures include…
- panedoscopy
- laryngoscopy
- bronchoscopy
- esophagoscopy (flexible or rigid scope)
- sinus surgery
common pathologies for endoscopy surgeries
- foreign body aspiration
- tumor/lesion
- vocal cord dysfunction
endoscopy anesthetic considerations
- manage brief periods of extreme stimulation
- avoid patient movement (consider lido, remi, and esmolol to block sympathetic stimulation)
- SHORT procedure so be careful with muscle relaxation
- constantly sharing airway with surgery
- use SMALL cuffed ETT (5-6 for adult)
- be prepared for intermittent apnea due to sharing of airway
jet ventilation
- manual ventilation using hand valve or mechanical device
- inspiration is high velocity jet stream (60 psi)
- expiration is passive
- may require TIVA because need to relax chest wall
contraindications for jet ventilation
- full stomach
- hiatal hernia
- trauma
high frequency jet ventilation indications
- used when limited access to airway
- done through small needle, ETT, catheter or side-port to a rigid bronchoscopy
- low Vt and high RR
- maintaining oxygenation can be difficult in certain patients
sinus surgery indications
- sinus obstruction (infection, polyps or tumors)
- sinusotomies
sinus surgery surgical options
- endoscopic (FESS) [most common]
- external
- flouro
- brain lab
sinus surgery anesthetic considerations
- GA vs MAC
- ETT vs LMA
- polyps associated with asthma and CF - reactive airway and allergies
- decrease bleeding with mild hypotension, vasoconstrictors, and deep anesthesia
sinus surgery complications
-dural puncture
treatment of dural puncture during sinus surgery
- d/c N2O
- ETCO2 25-30 mmHg (hyperventilate)
- mild hypotension
- place foley
- consider mannitol 25-50 g IV
- patch by surgeon (dural patch)
- deep extubation to prevent coughing and potentially worsen dural puncture
foreign body aspiration
- leading cause of accidental death in children <4 years
- most aspirated items are food particles but can also include beads, coins, pins or parts of small toys
S/S foreign body aspiration
- wheezing
- coughing
- aphonia
- cyanosis
foreign body aspiration anesthetic management
- depends on size and location of object
- larynx = laryngoscopy and removal with Magills
- distal larynx or trachea = rigid bronch, mouth guard to avoid injury, tracheal tears, inadequate ventilation
other anesthetic considerations for foreign body aspiration
- inhalation induction with 100% oxygen (maintain spontaneous respiration)
- administer antisialogogue, H2 blocker, and prokinetic
- coughing, bucking or straining must be avoided
- be cognizant of full stomach - RSI- full airway obstruction; surgeon must be prepared to perform emergency trach or cricothyrotomy
- observe for vagal stim during procedure
foreign body aspiration post op considerations
- return of airway reflexes
- edema possible for up to 24 hours - check cuff leak
- supportive measures = racemic epi, bronchodilators, steroids
nerves most often monitored during ENT surgery
- facial
- recurrent and superior laryngeal nerves
- vagus
- spinal accessory nerve
myringotomy
- tubes placed in the tympanic membrane to reduce middle ear pressure
- children who have chronic otitis media (fluid in the ear)
- recurrent otitis media = three or more acute infections in a 6 month period (or four in a one year period) usually accompanied with URI
myringotomy anesthetic considerations
- short operations (usually so short you dont even place a PIV)
- sedative may outlast procedure
- mask induction with sevo
- usually mask management with assisted ventilation
- abx and steroids placed in ear
- mild pain meds given orally or rectally
tonsillectomy and adenoidectomy indications
- pediatric = recurrent infections, airway obstruction
- adults = OSA, UPP, comorbidities like CHF
T&A anesthetic considerations
- peds vs adult = inhalation vs IV induction
- oral RAE tube maybe reinforced
- cuffed better
- secure ETT midline under lower lip
- eye protection for patient
- mouth gag
- HOB turned
- meds (decadron and zofran bc high risk PONV; more painful for adults)
- throat pack
- OGT suction
- EBL A LOT (4 ml/kg)
- IVF
T&A emergence considerations
- protect airway reflexes
- reduce risk of laryngospasm
- minimize coughing (topical vs IV lido)
T&A post surgery re-bleed
0.3-0.6 %
75% occur in first 6 hours
25% occur within 24 hours
-anesthetic considerations for rebleed = hypovolemic and full stomach (RSI)
septoplasty
-correct deformities in nasal septum
rhinoplasty
- repair or reshaping of the nose
- cosmetic
- airway restoration
nasal fractures
-closed vs open reduction
middle ear procedures
- middle ear = air-filled space between the tympanic membrane and oval window
- common surgeries = tympanoplasty, stapedectomy, ossiculoplasty, mastoidectomy, cochlear implants
middle ear procedures surgical considerations
- congenital defects
- trauma
- treatment of disease
- may use hypotensive technique to get bloodless field
- microsurgery
middle ear procedures anesthetic considerations
- GA = avoid nitrous, muscle relaxants avoided
- LA = ability to test hearing during surgery is good
- PONV common
- may use controlled hypotension
- deep extubation
tympanoplasty indication
perforated eardrum
tympanoplasty surgical approach
- post-auricular, posterior auditory canal
- temporal fascial graft, ossicular chain abnormalities repaired with prosthesis
mastoidectomy
- cells are open air
- indications = cholesteatoma, mastoiditis
- approach = entry through post auricular region
- anesthetic considerations - avoid muscle relaxation and N2O
thyroid surgery indications
- thyrotoxicosis
- malignancies of thyroid gland
thyroid surgery preop anesthetic considerations
- euthyroid
- medications (thyroid and beta blockers)
- airway assessment
thyroid surgery anesthetic considerations
- regional anesthetic - combined deep and superficial cervical plexus block
- direct acting vasopressor (neo)
- rose position with arms tucked (second IV)
- eye protection, goggles
- GETA
- NIMs tube - ensure electrodes contact right and left vocal cords
thyroid surgery postop anesthetic considerations
- hypocalcemia - s/s development within 24-96 hours
- RLN damage - unilateral more common, hoarseness
- bilateral mroe serious (biphasic stridor, dyspnea, respiratory distress, aphonia)
- hematoma - airway obstruction and asphyxiation
cleft palate and lip
- common craniofacial abnormality (1:7000)
- facial bones fuse by 9th week of development
- 30% have other congenital abnormalities (down syndrome, pierre robin, treacher collins)
- two stage repair (3 months = cleft lip repair with primary tip rhinoplasty; 8 months = closure of hard palate)
cleft palate and lip preop anesthetic considerations
- rules of ten
- weight = 10 pounds
- hemoglobin = 10 g
- WBC less than 10,000/mm3
- age - greater than 10 weeks
cleft palate and lip intraop anesthetic considerations
- standard induction
- oral RAE tube
- remove air from ALL lines
- eye protection
cleft palate and lip postop anesthetic considerations
- suture placed through tip of tongue to act as oral airway; prevents damage to palatal repair
- suction prior to extubation, reduce oral secretions and potential for laryngospasm
- consider mittens or armboards so kid doesn’t fuck with sutures
dental restoration why under anesthesia?
- not appropriate for office visit
- rampant cavities
- history of CP or down syndrome
- uncooperative
dental restoration preop anesthesia considerations
- oral midaz (0.5 mg/kg)
- IM ketamine (3-4 mg/kg)
dental restoration intraop anesthesia considerations
- standard induction
- nasal intubation
- afrin
- warmed RAE ETT
- nasal trumpet dilation
- throat pack
- OGT suction
- deep extubation
anesthesia goals for facial trauma
- secure airway without causing additional damage or compromising ventilation
- management of airway will depend on the situation
- may also have injury to head and neck so may need in-line stabilization until cleared
airway obstruction in trauma related to what?
- edema
- bleeding
- intraoral fractures
- nasal passage injury
- foreign bodies
severe facial or neck trauma airway management
- retrograde wire
- jet ventilation via cricothyrotomy
- emergent trach
LeFort fracture
determined common fracture lines along the maxilla and face
LeFort I
horizontal fracture extending from the floor of the nose and hard palate through the nasal septum
LeFort II
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
LeFort III
separates the midfacial skeleton from the cranial base traversing the root of the nose, ethmoid bone, eye orbits and sphenopalatine fossa
facial trauma anesthesia considerations
- avoid nasal intubation
- consider other trauma (cervical, thoracic, and abdominal)
- correct ABCs before addressing facial trauma
- anticipate extensive blood loss (type and cross, deliberate hypotension if tolerated)
- consider remaining intubated
- awake intubation to maintain airway reflexes
- cutting tools attached to the patient or available at the bedside
radical neck dissection
-resection of cancerous tumors of head and neck
radical neck dissection frequent comorbidities
- elderly
- smoking
- ETOH abuse
- CV disease
- history of radiation therapy
radical neck dissection anesthetic considerations
- airway management (CT results, consult surgeon, preop exam)
- preop labs incl type and cross
- two large bore IVs
- arterial line (tight BP control and for labs)
- muscle paralysis
- controlled hypotension
- minimize vasoconstrictors (like direct ones i.e. neo to maintain flap perfusion!)
- strict I&O
- vagal response so have anticholinergic ready
- may include trach or laryngectomy
- hyper oxygenate patient
- move ETT to level above transection
radical neck dissection postop considerations
- trach care
- controlled ventilation
- CXR to r/o pneumo
- monitor for laryngeal edema
- ICU –> edema, fluid shifts, altered ventilation, extensive anesthesia time
