Test 3: HEENT (PT 1/2) Flashcards
Which part of the nasal cavity is highly vascular and may lead to severe bleeding?
Turbinates
What are the functions of the larynx?
vocalization/articulation & protection of airway/allows respiration
What is innervated by the Internal Branch of the Superior Laryngeal Nerve?
laryngeal mucosa above vocal cords (inferior epiglottis
What is Sensory innervated by the Recurrent Laryngeal Nerve?
laryngeal mucosa below vocal cords
What is innervated by the Glossopharyngeal Nerve?
-superior aspect of epiglottis & base of tongue
-Motor + sensory for base of tongue, nasopharynx, & oropharynx
-Responsible for eliciting the gag reflex
What is innervated by the External Branch of the Superior Laryngeal Nerve?
Motor to the cricothyroid muscles (adduction-tension/elongation VC))
What is Motor innervated by the Recurrent Laryngeal Nerve?
all intrinsic muscles except cricothyroid (lots of actions)
What does the Facial Nerve supply innervation to?
motor and sensory supply to the muscles for facial expressions
What does the Trigeminal Nerve supply innervation to?
3 Branches: ophthalmic, maxillary, mandibular
sensory & motor to the nose, sinuses, palate, and tongue. Aid in motor control of face & in mastication
The RLN & SLN lie in close proximity to the _____
lateral lobe of the thyroid gland
What supplies innervation to the 6 extraocular muscles?
innervation by CN3 except SO4 LR6
How do you deal with the Shared Airway in ENT surgery?
-Requires planning and effective communication
-Maintenance of adequate ventilation and security/patency of ETT
-Constantly assess adequacy of ventilation (observe chest excursion, auscultation, SpO2, EtCO2, inspiratory pressures)
-Bubbling noises or smell of anesthetic gas = ETT cuff problem or migration above the vocal cords
-Surgeons may request periods of apnea, jet ventilation, or spontaneous respiration (may be difficult to maintain TIVA)
-Surgeons may insert throat packs to prevent blood/debris aspiration
-Must document time of insertion & removal!
Explain Deliberate Controlled Hypotension
-Reduce MAP to reduce blood loss
-Maintain MAP around 60mmHg or 20% decrease from baseline (chronic htn may require a higher MAP)
-Must maintain cerebral + renal autoregulation as well as coronary blood flow
-Arterial BP monitoring = required!
What agents are used to produce deliberate, controlled hypotension?
Vasodilating agents, BB, CCB, ultrashort-acting opioids (remifentanil), inhalational agents
What are the local anesthetics used in ENT surgery?
(most common = amide-based drugs)
Cocaine, Lidocaine, Benzocaine, Bupivacaine, Mepivacaine, Dyclonine
Common in nasal/sinus surgery. Topical/local anesthesia may be sole agent
What is the only local anesthetic with vasoconstrictive ability?
Cocaine (blocks catecholamine reuptake)
What vasoactive meds are commonly used in ENT surgery?
-Epinephrine: May be added to local anesthetic solutions to produce vasoconstriction
-Prolongs DOA of LA & decreases systemic absorption
What anticholinergic meds are used in ENT surgery?
Used for antisialagogue effects (dry secretions)
-Glycopyrrolate = better choice than atropine bc less tachycardia. Glyco does not cross BBB so no sedation
Why are corticosteroids used in ENT surgery?
-Ex: Dexamethasone
-Decrease laryngeal edema, reduce N/V, prolong analgesia of LA
-Administer as early as possible to reach peak prior to surgery
What PONV prophylaxis is used in ENT surgery?
-5HT3 antagonists (ondansetron)
-Dexamethasone
-TIVA vs inhalational (avoid N2O)
-Multimodal Pain mgmt/opioid sparing
What is important to know about throat packs?
-Must document insertion & removal time
-Throat packs placed to prevent blood from entering the stomach causing N/V
-Used in a variety of settings…dental, cleft lip/palate
Detail positioning concerns regarding ENT surgery?
-Head is prepped, draped, or wrapped in towels, limiting access to ETT & breathing circuit
-ETT is positioned and secured (tape or suture). RAE ETT = common.
-Disconnect tube prior to turning to prevent inadvertent disconnect
-OR table may be turned 90-180 degrees = HOB/airway away from you
-*Remember to add extensions and disconnect circuit when turning bed
-Added length placed prior to draping
-Signs of air leaks (bubbling, air escaping, smell of gas) = more sensitive indicators of leak than mechanical airway monitors
-Arms tucked at side
-Must ensure IV patency, consider 2 IVs for longer procedures
What is important to monitor when using a RAE ETT?
Watch for pressure on nares/lips.
-Forehead padding
What is a more sensitive indicator of an ETT leak than mechanical airway monitors?
Signs of air leaks (bubbling, air escaping, smell of gas)
What nerves do you need to worry about identifying, isolating, and preserving during ENT surgery?
Motor branch of CN7, Recurrent/inferior laryngeal/CN10, CN11
What allows for real time ID/functional assessment of vulnerable nerves?
EMG
How can you perform Intraoperative neurophysiologic monitoring?
Via Brainstem evoked potentials, electrocochleogram, EMG
Describe the “balanced anesthetic technique” utilized with neuromonitoring in ENT surgery?
-TIVA preferred, indifferent to opioids and nitrous oxide
-NMBA = only used for intubation
-LA are contraindicated (suppressant effect on muscle action)
What does the SLN innervate?
mucosa above VC, cricothyroid muscle, tension/elongation of VC
What does the RLN innervate?
mucosa below VC, all intrinsic m except cricothyroid, relaxes/abducts/adducts VC
What does the Glossopharyngeal Nerve innervate?
epiglottis, tongue, gag reflex
What is the motivation for using a different than normal ETT for ENT surgery?
Purpose of various ETT types = reduce cuff pressure on the tracheal wall
What is a RAE ETT?
Preformed right-angled ETT prevents ETT kinking, but tip may rest too distal or proximal
Requires careful placement check
What surgeries would utilize an Oral RAE?
cleft palate, T&A, UPPP, eye, upper face
What surgeries would utilize a Nasal RAE?
maxillofacial surgery, cosmetic, oral cavity, malocclusion, mandible
In what situations would you avoid nasal intubation?
Avoid nasal intubation in unconscious patient w facial trauma to prevent possible penetration of the brain
What is the purpose of using an Armored or Reinforced ETT?
-Embedded coiled wire to produce greater flexibility and memory
-Resist kinking & retain original integrity
-Useful when acute neck flexion/severe angles of ETT required
What is the purpose of using a Laser/Metal-Impregnated ETT?
-reduce risk of airway fire
-Cuff filled with methylene blue dyed saline to prevent ignition/early detection
-Reflective tape not adequate to prevent fires (bc dry & flammable)
What is the purpose of using an LMA?
-Used to facilitate intubation & control the airway
-Does not produce tracheal stimulation, Incidence of coughing = lower than ETT, No need for NMB, Conduit for surgical access to the glottis & trachea, Means of isolating the glottis from pharyngeal bleeding
What is the purpose of the NIM (Neural Integrity Monitor) ETT?
-Monitors electromyogram (EMG) → must be positioned correctly with markings on ETT between vocal cords
-Used for recurrent laryngeal nerve preservation
-If nerve is stimulated a response generated at the vocal cords gives an auditory alarm (beep)
What is important to know regarding NMBA and the use of a NIM ETT?
-Surgical procedures cannot use NMBA
-Sch used for intubation, NDMR used for intubation/positioning
-Either let Sch wear off or may have to reverse NDMR
What is the purpose of using a Microlaryngoscopy ETT?
-Used for vocal cord & tracheal stenosis surgeries
-Longer ETT w smaller diameter (increased resistance to ventilate)
-Assist with ventilation to decrease WOB
What is the purpose of using Jet Ventilation?
-Used for laryngeal surgery when trachea is not intubated
-May be performed manually w hand valve attached to O2 source
-Mechanical device allows to adjust rate and O2 concentration
What does LASER stand for?
“Light amplification by stimulated emission of radiation”
What are the components that make up a Laser?
Energy source + material that excites to emit light
What are the most common types of Lasers?
Each laser has specific medical application – CO2 & Nd:YAG most common
What are the safety considerations to note when using Laser?
-Must use protective eyewear for patient & staff (lens color specific)
-Noxious fumes: particulate from suction plume can lead to pulmonary issues
-Staff wear special masks when laser HPV lesions
-Small ETT or MLT must be removed during laser (or use special laser ETT)
-Lowest concentration O2 possible, FiO2 <30% NO N2O!
-Post warning signs of laser use outside operating area
-Patient’s eyes protected with appropriate colored glasses/wet gauze
-Matte-finish surgical instruments reduce beam reflection/dispersion
-Lasers in STANDBY mode when not in use
-Inflate cuff w methylene blue saline
-Add adjacent tissues shielded w wet gauze
-Plume suctioned/evacuated from surgical field
-Stop supplemental O2 at least 1 min before & during use of ESU/laser
Why do you avoid N2O when using Laser?
Avoid N2O bc it supports combustion
