Head Neck ENT Flashcards
What are the options for maintaining oxygenation during shared airway surgical procedures?
SS_HN 1.7
IPPV
Jet vent
SV + HFNO
https://academic.oup.com/bjaed/article/6/1/28/346997
What are the key features in the pre-operative assessment of a patient presenting with both emergency and non-life- threatening airway obstruction who will require a GA for airway surgery?
SS_HN 1.8
OST
What are the risks of the topical use of cocaine for nasal surgery?
SS_HN 1.13
Max dose 1.5mg/kg
MOA:
1. Uptake 1
2. MAO-i
Dec uptake of
1. NAd
2. Da
3. 5HT
CVS (SNS stim)
1. Tach
2. HTN
3. Cor vasospasm**
4. MI
5. Vent arrhy
CNS
1. Euphoria
2. Hallu
3. Seizzure
4. Hypertherm
5. Coma
Petkov P. 178
What technique do you use to achieve a smooth, cough-buck- free emergence from General Anaesthesia?
SS_HN 1.15
Prop+Remi
Remi wakeup
What are the indications for, and anaesthetic implications of, intraoperative facial nerve monitoring?
SS_HN 1.16
Discuss the indications, method and implications for anaesthetic management of monitoring facial nerve function intraoperatively
Indications x3
1. Posterior fossa operations
2. Middle ear/mastoid
Mastoidectomy / cochlear implant
Parotidectomy
Accoustic neuroma
BOS
How
1. EMG on obicularis oculi and oris
2.
What is your plan for anaesthesia for a post-tonsillectomy bleed in a 2yr old?
SS_HN 1.17
- 3% cases
- within 24h
- 0.8% require op
Pre:
Hypovol –> fluid resus + large bore IVC
Airway –> suction x2, smaller ETT, aspiration risk
Anxiety
NGT
RSI
Extubate head down awake
Close monitoring post op
Important risk factors to consider in a child who is bleeding after tonsillectomy are as follows:
- Potential hypovolaemic shock
- Pulmonary aspiration (of regurgitated swallowed blood or postoperative oral intake)
- Potential difficult intubation – bleeding obscuring the view, oedema from previous airway instrumentation and surgery.
- A second general anaesthetic
Oxford Advanced P. 226
https://academic.oup.com/bjaed/article/7/2/33/384229
https://resources.wfsahq.org/atotw/anaesthesia-for-bleeding-tonsil/
How is the risk of airway fire minimised and how would you manage an airway fire?
SS_HN 1.18
Triad
1. O2 - keep low FiO2
2. Flammable - use TIVA
3. Combust - N2O, ETT
Laser Fire Drill
1. Laser off
2. Stop O2
3. 50mL saline flood site
3. Maintain venti with FM + TIVA
4. Bronch
5. Reint + CXR
6. ICU
Oxford Advanced P.228
See ANZCA PS
What are the key questions to ask to plan your approach to anaesthetic induction and securing the airway in the patient presenting for repair of a mandibular fracture?
SS_HN 1.21
Trauma:
Qs:
- MOI
- AW obs - hypoxia, stridor, dyspnoea, drooling, trismus, voice change, surgical emphysema
- Cooperation - hypoxia, intox, brain injury
- C-spine?
Aspiration risk - last eaten
ATLS principles
Awake - need cooperative
RSI + preoxy++
DI equipment
Mandibular #
1. Trisums - relax post induction and ~ pain
- TMJ # / zygomatic impingement
Nasal intubation
- vasoconstrictors
- blind
- awake/asleep with fibreoptic
You are called to PACU as your patient is bleeding continuously after tooth extraction under GA. How do you manage and investigate this?
SS_HN 1.24
Initiation phase: pressure packs, suture, bone wax, cellulose, styptics, gel foam, tranexamic acid, aminocaproic acid, cryoprecipitate, desmopressin (DDAVP), factor VIII concentrate and prothrombin complex concentrate (PCC) act at different stages of this phase.
Amplification phase: ethamsylate, haemostatic collagen and Actcell® act during this phase.
Propagation phase: cryoprecipitate and recombinant factor (VIIa) act during this phase.
Interventions for treating post‐extraction bleeding
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6494262/
Provide safe anaesthesia care for patients undergoing electro- convulsive therapy (V)
How does your technique of general anaesthesia influence the effectiveness of ECT?
SS_HN 2.5
Propofol
Opioid - reduce propofol dose, improve quality of seizures
Remi (1mcg/kg) / alf (10-25mcg/kg)
Sux (0.5-1mg/kg)
- avoid in NMS/MH/burns/pseudochol def
Miv but histamine release ++
Oxford Adv P. 335
ECT
What is the physiological response to ECT?
SS_HN 1.27
CNS CVS
CNS:
1. gen seizure
- inc CBF
- inc ICP
- inc CMRO2
dizziness/headache/agitation/ST mem loss
TIA, ICH, cortical blindness
CVS
1. ANS activation
** PNS then SNS
10-15s then 5mins **
- sBP 30-40%+
- HR 20%+
- inc VO2 myocardial
(worsen by hyperven hypocap)
Transient IOP IGP increase
Risk
1/1:10000
CVS
pulm asp
severe laryngospasm
Maxfacs
Outline the types of facial, maxillary and mandibular fractures and their surgical management
UPPER/MID/LOWER
1/3
UPPER
1. ** Frontal, sphenoid **
**Mid = Max ** NOZ
1. MAX + nasal/orbital/zygoma
LE FORT
Floating Palate/maxilla/face
Life saving measures:
1. Epistats
2. Rapid Rhinos
3. Foley
4. Bite block
Lower
1. Mandible
Ring –> breaks 2+ places
Maxfacs
Discuss the anaesthetic management of patients requiring surgical fixation of facial, maxillary and mandibular fractures
[20B03] A young adult male is assaulted & sustains a maxillary fracture. He is scheduled for an ORIF of the maxillary fracture on the emergency list. Outline the relevant anaesthetic considerations.
Preop:
1. Ax - usual + AW
?Trismus ?soft tissue swelling
2. Assoc injuries? C-spine
3. Nostril patency
4. BOS # –> CSF leak –> CI nasal tube + NPA + THRIVE/HiFlow
5. Imaging
Intraop
BMV - diff 2o jaw move/swelling
Intubation
- trismus tends to relax MO post induction
* zygomatic / orbit = south oral RAE
* Mandibular / Le Fort = nasal
Technique
1. AFOI
2. RSI appropriate
3. Diffic inh ind
ALT
1. Tracheostomy
2. Submental
Monitoring
1. Throat pack
2. Facial nerve mon
3. Steroids for swelling
4. Analgesia
5. Abx
GC/TP/OST
ENT - thyroid - preop
Discuss the anaesthetic management of patients requiring thyroid or parathyroid surgery. In particular:
Head/Neck – thyroidectomy 1
[17B08] Discuss the preoperative assessment for a patient who presents for thyroidectomy.
- Mass effect
- AW
- Adj structure
- Endocrine
ENT - thyroid - TFT / thyrotoxocosis
Head/Neck – thyroidectomy 2
[12A08] A 35-year-old female is booked for thyroidectomy.
Her blood results are as follows.
Thyroid stimulating hormone (TSH, thyrotropin) Total Thyroxine (Total T4)
Free Thyroxine (Free T4)
Free Tri-iodothyronine (Free T3)
0.1 (N 0.3 – 3 mIU/l) 20 (N 4 – 11 μg/dl)
4 (N 0.7 – 1.8 ng/dl) 120 (N 60 – 175 ng/dl)
a. Interpret the thyroid function tests (10%)
b. Justify when you would proceed to thyroidectomy in this patient (50%)
c. What is the management of an intraoperative thyrotoxic crisis? (40%)
a) interpret TFT
TSH Low
T4 High
T3 N (more bio active)
1o hyperthyroidism
b) when to proceed?
6-8/52 with carbimazole / PTU
indication:
1. HR < 80
2. no tremor
3. TFT - normal T4 but TSH may be low still
c) Mx Intraop thyrotoxic crisis
Def: Life threatening exac of hyperT state + decomp in 1+ organ
Mortality 20-30%
6-24hr post op but also can intraop
Sx:
- fever, tachy, sweating
- CVS
- CNS
- GI
Imm
- ABC 100% O2
- IV saline - rehydrate
- Sponging and paracetamol - hyperpyrexia
- Propanolol 1mg to 10
Esmolol
- Hydrocort for adrenal insuff
Subsequent Mx
- PTU
- sodium io
