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

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

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

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