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N931 Advanced Principles of Anesthesia I > ENT Surgeries > Flashcards

ENT Surgeries Flashcards

1
Q

four cranial nerves that supply sensory and motor function to the airway

A
  • trigeminal (CN V)
  • glossopharyngeal (CN IX)
  • facial (CN VII)
  • vagus (CN X)
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2
Q

trigeminal nerve

A

-provides sensory innervation to the face

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3
Q

three divisions of the trigeminal nerve

A
  • opthalmic (V1)
  • maxillary (V2)
  • mandibular (V3)
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4
Q

anterior ethmoid nerve

A
  • terminal branch of V1
  • opthalmic nerve
  • innervation = sensory to nares and anterior 1/3 of nasal septum
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5
Q

spenopalatine nerve

A
  • branch of V2

- innervation = turbinates and posterior 2/3 of nasal septum

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6
Q

lingual nerve

A
  • branch of V3

- innervation = sensory to anterior 2/3 of tongue

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7
Q

glossopharyngeal nerve

A
  • provides sensory innervation to –> posterior 1/3 of the tongue, oropharynx, vallecula, anterior epiglottis
  • also the afferent limb of the gag reflex
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8
Q

facial nerve

A
  • located at the tragus of the ear

- supplies motor and sensory function to the face for facial expressions

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9
Q

branches of the facial nerve (6)

A
  • the zebra bit my cousin paul

- temporal, zygomatic, buccal, mandibular, cervical, posterior auricular

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10
Q

six major branches of the facial nerve

A
  • anterior = temporal, zygomatic, buccal, mandibular
  • inferior = cervical
  • posterior = posterior auricular
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11
Q

vagus nerve branches

A
  • SLN

- RLN

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12
Q

superior laryngeal nerve

A
  • 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)
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13
Q

recurrent laryngeal nerve

A
  • 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
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14
Q

risk factors for RLN injury

A
  • external pressure from ETT or LMA
  • injury from thyroid/parathyroid surgery
  • excessive neck stretching
  • neoplasm
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15
Q

L RLN specific risk factors for injury

A
  • PDA ligation
  • LA enlargement dt mitral valve stenosis
  • aortic aneurysm surgery
  • thoracic tumor resection
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16
Q

acute unilateral RLN injury

A
  • affected cord assumes adducted, paramedian position

- hoarseness

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17
Q

bilateral RLN injury

A

-respiratory distress, stridor, requires EMERGENCY airway

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18
Q

arterial anatomy of head/face (HEENT)

A
  • increased vascularity compared to other parts of the body
  • carotid
  • facial
  • maxillary
  • superficial temporal
  • deep temporal
  • superior thyroid
  • buccal
  • middle meningeal
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19
Q

veins of face, head, and neck

A
  • deep = internal jugular, maxillary, vertebral

- superficial = external jugular, superficial temporal, occipital, facial

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20
Q

common ENT surgery considerations

A
  • 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
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21
Q

common vasoactive drugs used in ENT

A
  • epi (1:200,000 – vasoconstriction)
  • cocaine - naturally occurring ester of benzoic acid
  • combo of these can lead to HA, HTN, tachycardia, and dysrhythmias
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22
Q

common LAs in ENT

A
  • cocaine 4%
  • lidocaine 2%
  • bupivacaine 0.25%
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23
Q

common anticholinergics in ENT

A
  • for antisialagogue effects
  • reduction of vagal tone
  • glycopyrolate preferred (0.2 mg)
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24
Q

common corticosteroids in ENT

A
  • dexamethasone
  • reduce N/V
  • inhibit production of prostaglandins so reduce pain and edema
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25
Q

PONV in ENT surgery

A
  • 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
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26
Q

deliberate controlled hypotension

A
  • 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
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27
Q

laser surgery

A
  • laser light beams used for thermal effect (have only one wavelength)
  • commonly used lasers in ENT = CO2, Nd:YAG, Argon
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28
Q

CO2 laser

A

longer wavelength

shallow depth and precise

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29
Q

Nd:YAG

A
  • neodymium-doped yttrium aluminum garnett
  • shorter wavelength
  • passes through superficial structures
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30
Q

laser safety

A
  • 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)
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31
Q

fire triad (for airway fire)

A
  • oxidizer = oxygen, nitrous oxide, room air
  • ignition source = ESUs, lasers, fiberoptic light source
  • fuel = alcohol based skin prep, surgical drape, patient
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32
Q

airway fire

A
  • 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
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33
Q

ways to prevent airway fire

A
  • metal impregnated ETT
  • saline filled ETT cuff
  • use lowest FiO2 possible
  • avoid N2O
  • avoid paper drapes
  • use water based lubricants
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34
Q

endoscopy procedures include…

A
  • panedoscopy
  • laryngoscopy
  • bronchoscopy
  • esophagoscopy (flexible or rigid scope)
  • sinus surgery
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35
Q

common pathologies for endoscopy surgeries

A
  • foreign body aspiration
  • tumor/lesion
  • vocal cord dysfunction
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36
Q

endoscopy anesthetic considerations

A
  • 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
37
Q

jet ventilation

A
  • 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
38
Q

contraindications for jet ventilation

A
  • full stomach
  • hiatal hernia
  • trauma
39
Q

high frequency jet ventilation indications

A
  • 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
40
Q

sinus surgery indications

A
  • sinus obstruction (infection, polyps or tumors)

- sinusotomies

41
Q

sinus surgery surgical options

A
  • endoscopic (FESS) [most common]
  • external
  • flouro
  • brain lab
42
Q

sinus surgery anesthetic considerations

A
  • 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
43
Q

sinus surgery complications

A

-dural puncture

44
Q

treatment of dural puncture during sinus surgery

A
  • 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
45
Q

foreign body aspiration

A
  • 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

46
Q

S/S foreign body aspiration

A
  • wheezing
  • coughing
  • aphonia
  • cyanosis
47
Q

foreign body aspiration anesthetic management

A
  • 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
48
Q

other anesthetic considerations for foreign body aspiration

A
  • 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
49
Q

foreign body aspiration post op considerations

A
  • return of airway reflexes
  • edema possible for up to 24 hours - check cuff leak
  • supportive measures = racemic epi, bronchodilators, steroids
50
Q

nerves most often monitored during ENT surgery

A
  • facial
  • recurrent and superior laryngeal nerves
  • vagus
  • spinal accessory nerve
51
Q

myringotomy

A
  • 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
52
Q

myringotomy anesthetic considerations

A
  • 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
53
Q

tonsillectomy and adenoidectomy indications

A
  • pediatric = recurrent infections, airway obstruction

- adults = OSA, UPP, comorbidities like CHF

54
Q

T&A anesthetic considerations

A
  • 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
55
Q

T&A emergence considerations

A
  • protect airway reflexes
  • reduce risk of laryngospasm
  • minimize coughing (topical vs IV lido)
56
Q

T&A post surgery re-bleed

A

0.3-0.6 %
75% occur in first 6 hours
25% occur within 24 hours
-anesthetic considerations for rebleed = hypovolemic and full stomach (RSI)

57
Q

septoplasty

A

-correct deformities in nasal septum

58
Q

rhinoplasty

A
  • repair or reshaping of the nose
  • cosmetic
  • airway restoration
59
Q

nasal fractures

A

-closed vs open reduction

60
Q

middle ear procedures

A
  • middle ear = air-filled space between the tympanic membrane and oval window
  • common surgeries = tympanoplasty, stapedectomy, ossiculoplasty, mastoidectomy, cochlear implants
61
Q

middle ear procedures surgical considerations

A
  • congenital defects
  • trauma
  • treatment of disease
  • may use hypotensive technique to get bloodless field
  • microsurgery
62
Q

middle ear procedures anesthetic considerations

A
  • GA = avoid nitrous, muscle relaxants avoided
  • LA = ability to test hearing during surgery is good
  • PONV common
  • may use controlled hypotension
  • deep extubation
63
Q

tympanoplasty indication

A

perforated eardrum

64
Q

tympanoplasty surgical approach

A
  • post-auricular, posterior auditory canal

- temporal fascial graft, ossicular chain abnormalities repaired with prosthesis

65
Q

mastoidectomy

A
  • cells are open air
  • indications = cholesteatoma, mastoiditis
  • approach = entry through post auricular region
  • anesthetic considerations - avoid muscle relaxation and N2O
66
Q

thyroid surgery indications

A
  • thyrotoxicosis

- malignancies of thyroid gland

67
Q

thyroid surgery preop anesthetic considerations

A
  • euthyroid
  • medications (thyroid and beta blockers)
  • airway assessment
68
Q

thyroid surgery anesthetic considerations

A
  • 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
69
Q

thyroid surgery postop anesthetic considerations

A
  • 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
70
Q

cleft palate and lip

A
  • 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)
71
Q

cleft palate and lip preop anesthetic considerations

A
  • rules of ten
  • weight = 10 pounds
  • hemoglobin = 10 g
  • WBC less than 10,000/mm3
  • age - greater than 10 weeks
72
Q

cleft palate and lip intraop anesthetic considerations

A
  • standard induction
  • oral RAE tube
  • remove air from ALL lines
  • eye protection
73
Q

cleft palate and lip postop anesthetic considerations

A
  • 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
74
Q

dental restoration why under anesthesia?

A
  • not appropriate for office visit
  • rampant cavities
  • history of CP or down syndrome
  • uncooperative
75
Q

dental restoration preop anesthesia considerations

A
  • oral midaz (0.5 mg/kg)

- IM ketamine (3-4 mg/kg)

76
Q

dental restoration intraop anesthesia considerations

A
  • standard induction
  • nasal intubation
  • afrin
  • warmed RAE ETT
  • nasal trumpet dilation
  • throat pack
  • OGT suction
  • deep extubation
77
Q

anesthesia goals for facial trauma

A
  • 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
78
Q

airway obstruction in trauma related to what?

A
  • edema
  • bleeding
  • intraoral fractures
  • nasal passage injury
  • foreign bodies
79
Q

severe facial or neck trauma airway management

A
  • retrograde wire
  • jet ventilation via cricothyrotomy
  • emergent trach
80
Q

LeFort fracture

A

determined common fracture lines along the maxilla and face

81
Q

LeFort I

A

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

82
Q

LeFort II

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

83
Q

LeFort III

A

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

84
Q

facial trauma anesthesia considerations

A
  • 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
85
Q

radical neck dissection

A

-resection of cancerous tumors of head and neck

86
Q

radical neck dissection frequent comorbidities

A
  • elderly
  • smoking
  • ETOH abuse
  • CV disease
  • history of radiation therapy
87
Q

radical neck dissection anesthetic considerations

A
  • 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
88
Q

radical neck dissection postop considerations

A
  • trach care
  • controlled ventilation
  • CXR to r/o pneumo
  • monitor for laryngeal edema
  • ICU –> edema, fluid shifts, altered ventilation, extensive anesthesia time

N931 Advanced Principles of Anesthesia I (19 decks)

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