Head Neck ENT

Question 1

What are the options for maintaining oxygenation during shared airway surgical procedures?

SS_HN 1.7

Answer 1

IPPV
Jet vent
SV + HFNO

https://academic.oup.com/bjaed/article/6/1/28/346997

Question 2

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

Answer 2

OST

Question 3

What are the risks of the topical use of cocaine for nasal surgery?

SS_HN 1.13

Answer 3

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

Question 4

What technique do you use to achieve a smooth, cough-buck- free emergence from General Anaesthesia?

SS_HN 1.15

Answer 4

Prop+Remi

Remi wakeup

Question 5

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

Answer 5

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.

Question 6

What is your plan for anaesthesia for a post-tonsillectomy bleed in a 2yr old?

SS_HN 1.17

Answer 6

• 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:

1. Potential hypovolaemic shock
2. Pulmonary aspiration (of regurgitated swallowed blood or postoperative oral intake)
3. Potential difficult intubation – bleeding obscuring the view, oedema from previous airway instrumentation and surgery.
4. 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/

Question 7

How is the risk of airway fire minimised and how would you manage an airway fire?

SS_HN 1.18

Answer 7

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

Question 8

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

Answer 8

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

2. TMJ # / zygomatic impingement

Nasal intubation
- vasoconstrictors
- blind
- awake/asleep with fibreoptic

Question 9

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

Answer 9

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/

Question 10

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

Answer 10

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

Question 11

ECT

What is the physiological response to ECT?

SS_HN 1.27

Answer 11

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

Question 12

Maxfacs

Outline the types of facial, maxillary and mandibular fractures and their surgical management

Answer 12

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

Question 13

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.

Answer 13

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

Question 14

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.

Answer 14

Issues
1. Thyroid dx
- euthyroid - HR< 80; no hand trem
- extent/sx approach
- 4M

2. Shared/diff AW
3. Post op
   - Blood loss (large retrosternal)
   - RLN damage (nim ett)
   - ParaThy damage (dec Ca++)
   - tracheomalacia
   - thyroid crisis

ER
1. Mass effect
2. AW
3. Adj structure
4. Endocrine

(64.4%) For a core clinical area this was a disappointing pass rate. Candidates fell into two groups:

• Good candidates demonstrated an understanding of thyroidectomy and the implications for anaesthesia by mentioning the
• thyroid mass effects,
• potential airway problems,
• problems with adjacent structures and
• endocrine issues and relating them
  back to anaesthesia.
• A significant number of candidates mentioned thyroid mass effects on the airway alone and therefore did not meet the
  borderline standard.

Question 15

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%)

Answer 15

a) interpret TFT

TSH Low
T4 High = 1o hyperthyroidism

T3 N (more bio active)

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

(84.1%) Key components:
- Interpretation of thyroid function tests
- thyrotoxicity reflected in high T4
- negative feedback represented by low TSH
- Justification of when to proceed with surgery
- the principle to aim for euthyroid conditions prior to surgery
- the possibility of an airway emergency
- anticipation of thyroid storm
- consideration of the time for drugs to take effect:
antithyroid drugs, beta blockers, anti adrenergics
- Management of thyroid crisis
- recognition of signs
- differential diagnosis
- supportive treatment
- specific treatment: beta blockade, antithyroid drugs, intravenous iodine and the place of glucocorticoid support

Question 16

[23A03]
A 30-year-old patient is scheduled for laser resection of a subglottic mass to relieve mild stridor.
Justify your intraoperative anaesthetic management of this case.

Answer 16

The anesthetic management for this 30-year-old patient undergoing laser resection of a subglottic mass requires careful consideration of several factors to ensure patient safety and optimal surgical conditions. Here is a justified approach to the intraoperative anesthetic management:

Airway Management

Preoperative Assessment:
- Evaluate the extent of airway obstruction and stridor severity[1][20].
- Review imaging studies to assess the size and location of the subglottic mass[1].

Intubation Strategy:
- Perform awake flexible bronchoscopic intubation to maintain spontaneous ventilation and assess the airway[1][2].
- Use a smaller endotracheal tube (e.g., 5.0-6.0 mm ID) to bypass the stenosis[1][2].
- Consider using a laser-resistant endotracheal tube to prevent airway fire[13][14].

Ventilation Management

• Maintain spontaneous ventilation initially to avoid potential complete airway obstruction[1][2].
• Once the airway is secured, transition to controlled ventilation with low tidal volumes and increased respiratory rate to minimize airway pressures[6].

Anesthetic Technique

Induction:
- Use inhalational induction with sevoflurane to maintain spontaneous breathing[1][14].
- Avoid muscle relaxants initially to prevent complete airway collapse[1][2].

Maintenance:
- Employ total intravenous anesthesia (TIVA) with propofol and remifentanil to avoid airway irritation and allow for rapid emergence[6][14].
- Titrate anesthetic depth carefully to balance surgical conditions and respiratory drive.

Monitoring

• Utilize standard ASA monitors plus:
  
  • Continuous end-tidal CO2 monitoring[6]
  • Arterial line for beat-to-beat blood pressure monitoring and blood gas analysis[6]

Laser Safety Precautions

• Set FiO2 to the lowest possible level (ideally < 30%) to reduce fire risk[13][14].
• Use saline-soaked gauze around the surgical field to protect adjacent tissues[13].
• Ensure proper laser safety protocols are followed by all OR personnel[13][14].

Emergence and Extubation

• Plan for a smooth emergence to avoid coughing and laryngospasm[1][2].
• Consider administering dexamethasone to reduce airway edema[1][8].
• Evaluate the airway with flexible bronchoscopy before extubation[1][2].
• Be prepared for possible reintubation or emergency tracheostomy[1][2].

Postoperative Care

• Monitor closely for signs of airway compromise or bleeding in the recovery area[1][8].
• Provide humidified oxygen and continue steroid therapy as needed[8].

This comprehensive approach addresses the unique challenges of subglottic laser surgery, prioritizing airway management, ventilation strategies, and laser safety while ensuring adequate anesthesia and monitoring throughout the procedure.

Sources
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