TRANS 33 to 36 Flashcards
The incision on the trachea is ultimately done at the level of
the
2nd to the 4th tracheal ring.
Metal tubes disadvantage?
do not have an
extension on its opening.
will not have a cuff
the balloon that
you usually see at the end of tracheostomy tube. This
normally prevents aspiration of fluid or blood into the distal
ends of the trachea after the surgery. It also provides a little bit of anchorage so that the tracheostomy tube is not
accidentally pulled out after it has been inserted.
Cuff
The demarcation line between the upper and lower airway is
GLOTTIS (TRUE VOCAL CORDS)
From the tip of the epiglottis going inferiorly up to about 1 cm above the true vocal cords at the area of laryngeal ventricle.
Supraglottis
The only complete ring in the laryngotracheal skeleton is supposed to be the
Cricooid cartialge
a palpable landmark to identify the superior aspect of the larynx in the midline.
Thyroid notch
a palpable depression between cricoid and thyroid cartilages. This is the location for an emergent cricothyrotomy.
Cricothyroid membrane
a palpable landmark to identify the junction of the larynx and trachea. The skin incision is typically placed 1-2cm inferior to this
Cricoid cartilage
a palpable landmark to identify the thoracic inlet. It is important to palpate here to the possibility of a high-riding innominate artery that may be encountered during tracheostomy.
Sternal notch
Most popularly known indication is for the relief of upper airway obstruction.
Point of obstruction should be higher than where you create your opening, otherwise you will not be able to bypass the obstruction—the demarcation line is the true vocal cords or the glottis (or 2nd to 4th tracheal ring). Anything above that is the upper airway.
UPPER AIRWAY OBSTRUCTION
V-shaped, with 2 vocal cords that will either abduct or adduct; the maximum abduction of the true vocal cords is about 20 mm (2 cm).
True vocal cords:
a spreading cellulitis of the floor of the mouth that will cause the tongue to be elevated and pushed backward; an acute medical emergency. Will not be resolved in 1-2 days.
Ludwig’s angina
What is prolonged intubation adult and children?
In an adult after 5 days, in a child after 7-10 days.
Most common complication of tracheostomy pag gingawa ng madalian?
Hemorrhage
Does patient in mechnical ventialtor still respiratory arrest?
What is the mechanism? – It happens to patients who are chronically obstructed
The only thing that is keeping them breathing is the hypoxic drive, because they have high levels of CO2 in the body. Then you puncture this trachea then out goes the carbon dioxide. The respiratory center will now have no more stimulus and the patient crashes.
What do we do? – You just cover the tracheostomy again so that carbon dioxide will build up once more and then release it little by little
If the patient is already in the operating room, ask the anesthesiologist to hook the patient in the anesthesia machine and do ventilatory support until such time the patient will have spontaneous respiration again
why does tracheal stenosis happen?
Usually, a complication caused by high tracheostomy
High tracheostomy – when the tracheostomy is done above the second tracheal ring
Low tracheostomy – when the tracheostomy is done below the 4th tracheal ring
Minsan kasi sap ag mamadali, di mo na mabilang, basta nagbutas ka nalang
Superior
boundary of Oral Cavity, before it becomes the
Oropharynx.
Posterior free margin of the Hard Palate
Lateral boundary of the Oral Cavity. Meaning, the palatine
tonsils and structures posterior to that belong to the
Oropharynx
Anterior Tonsillar Pilar / Palatoglossus Muscles
Divides the tongue into anterior
2/3 and posterior 1/3. It is also the posteroinferior limit of the oral cavity, which implies that the base of the tongue
(posterior 1/3 of the tongue) is already Oropharyngeal
Circumvallate Papillae
Immediately behind the nasal cavity.
Bounded superiorly by the skull base, and inferiorly by the
horizontal plane of the hard palate.
A compartment or space that exclusively accommodates
AIR. Food does not routinely pass in this area.
NASOPHARYNX
inferior limit of the nasopharynx
epipharynx
The Mesopharynx. Extends until the tip of the epiglottis.
It is the interphase area where BOTH food and air can
pass through.
OROPHARYNX
From the tip of the epiglottis until inferior margin of the
cricoid cartilage, you have the
Laryngopharynx or the
Hypopharynx
the upper most component, located in the nasopharynx. In common layman’s term, this is called the ADENOID – this is the only unpaired component in the Waldeyer’s Ring
NASOPHARYNGEAL TONSIL
Going inferiorly and laterally, you have lymphoid tissues which surround the eustachian tube opening, also in the nasopharynx. These are called _________These are PAIRED, because you have two eustachian tubes
TONSILS OF GERLACH
Immediately below the Eustachian Tube, you have the Lymphoid Aggregated within Rosenmüller Fossa – which is a depression immediately inferior to the Eustachian Tube opening. You have lymphoid aggregates here but no special name, so it just called lymphoid aggregates of
ROSENMÜLLER FOSSA
Going further inferiorly in the area of the Oropharynx, you have the most popular tonsil
palatine tonsil
Immediately posterior to the Palatine Tonsil, is the Lateral Pharyngeal Bands. These are the follicles that usually become prominent when you have Pharyngitis. This is the part of the Pharynx that swells, becomes butlig-butlig, and cause frequent clearing of the throat.
LATERAL PHARYNGEAL BANDS
Located in the base of the posterior tongue.
Lingual Tonsil
- From the Greek Term a and pnoia – “want of breath”
* Cessation of respiration for at least 10 SECONDS
Apnea
- Airflow reduction by > 30% for at least 10 seconds with >4% oxyhemoglobin desaturation OR
- Airflow reduction by >50% for at least 10 seconds with >3% oxyhemoglobin desaturation OR
- An EEG arousal
Hypopnea
Hypopnea?
- Airflow reduction by > 30% for at least 10 seconds with >4% oxyhemoglobin desaturation OR
- Airflow reduction by >50% for at least 10 seconds with >3% oxyhemoglobin desaturation OR
- An EEG arousal
In HYPOPNEA, there is decrease in respiratory rate by criteria:
either a > 30% or 50% decrease in respiratory rate, with an accompanying oxygen desaturation by at least >4% or 3% (depending on what criteria is used). OR, it is marked by a period of unconscious arousal (nagigising yung tao kapag tulog).
Episodes should also last at least 10 seconds.
Sequence of breaths for at least 10 seconds with increasing respiratory effort or flattening of the nasal pressure waveform leading to an arousal from sleep when the sequence of breaths does not meet the criteria for an apnea or a hypopnea.
RESPIRATORY EFFORT – RELATED AROUSAL (RERA)
• Cessation of respiration due to discontinuance of respiratory effort.
Apnea that occurs because there is defect in the respiratory center. There is lack of impulses caused by deficiency in the respiratory center.
central apnea
• Cessation of airflow in the presence of continued inspiratory effort
There is NO PROBLEM with the respiratory center.
The Apnea ensues because there is an obstruction in the airway.
Example of this is → OBSTRUCTIVE SLEEP APNEA SYNDROME
PERIPHERAL/OBSTRUCTIVE APNEA
• Starts as CENTRAL, proceeds to become OBSTRUCTIVE
Usually starts as a central phenomenon, and then it evolves to include a peripheral or obstructive component.
Mixed apnea
What is important in these indices, when you measure these phenomena, these are measured within
1 hour
So, when you say that the APNEA INDEX of the patient is 10 – then that means the patient is suffering from
10 APNEA EPISODES PER HOUR OF SLEEP.
• APNEA INDEX < 5
• No complaints of excessive daytime sleepiness
MILDEST form of SDB.
In primary snoring, patient is just a loud snorer. But there NO evidence that the snoring is producing long term problems.
But since OSAS has to start somewhere, and the snoring is proof that the patient is undergoing some form of upper airway obstruction while asleep.
Primary Snoring
- APNEA INDEX < 5
- RERA INDEX > 5
- Abnormal Intrathoracic Pressure (>10cm water)
UPPER AIRWAY RESISTANCE SYNDROME
• Sleep-associated respiratory events (apnea, hypopnea, RERA) lasting at least 10 seconds per episode
• RESPIRATORY DISTURBANCE INDEX of 5 and above is said to be significant and diagnostic.
The full-blown disease, where in the patient will either develop an apnea, hypopnea or RERA, occurring DURING SLEEP. It has to be sleep associated.
OSA
OSAS – DIAGNOSTIC CRITERIA
- EXCESSIVE DAYTIME SLEEPINESS
- WITNESSED REPORTS OF APNEA AND/OR SNORING
- TERMINATED BY A BRIEF UNCONSCIOUS AROUSAL FROM SLEEP – WAKING WITH GASPING, CHOKING OR BREATH-HOLDING
- RESPIRATORY EVENT INDEX OF 5/HOUR
- ALTERNATIVELY: Respiratory Event Index of 15/hour
a boot-shaped heart seen in radiography because of right ventricular hypertrophy
Coeur en sabot
This is the most important factor that may predispose to OSAS/SDB, that’s why it is important in your History and PE to take note of the BMI. BMI of >25 clearly predisposes an individual to OSAS.
OVERWEIGHT, OBESITY
-Allows you to prognosticate or predict who are a candidate for OSAS
can pinpoint the site of obstruction
FUJITA CLASSIFICATION
Type 1 2 and 3 in fujita classification?
• Type I – Retropalatal
• Type II – Retropalatal & Retrolingual
Type III – Retrolingual
the one mostly at risk for developing OSAS in fujita classi?
Type 2
MODIFIED MALLAMPATI CLASSIFICATION types 1 to 4?
I – Entire uvula can be seen with tongue at rest.
II – partial view of uvula is seen.
III – only the soft and hard palate can be seen.
IV – only hard palate can be seen
mallampati classification that is more prone to develop osa?
MALLAMPATI 4
OSAS Symptomatology?
- Excessively loud snoring
- Apnea periods with “gasping” episodes
- Excessive daytime somnolence
- Morning fatigue
You can also order conventional x-rays which are noninvasive techniques. You have to specify and order a
for osas
SOFT TISSUE LATERAL XRAY OF THE HEAD
Findings in xrays in OSA
What you are trying to detect here will be the hypertrophy of your adenoid or tonsils. And this will not be caught by your standard x-rays because it gives soft tissue shadows.
You measure the bony protuberance of the skull to predict possible choke points in the upper airway
However, it is not a very popular method for evaluating OSAS. Because we have CT scan or MRI.
CEPHALOMETRY
MULLER MANEUVER?
while doing the flexible nasolaryngoscopy, you close the nose and ask the patient to shut their mouth, and ask them to inhale/inspire. The act of inspiration with the nose closed and the mouth shut will produce negative pressure within the upper airway.
what drugs are used in drug induced sleep endoscopy?
o Using Dexmedetomidine, Midazolam or Propofol
what is the drawback of drug induced sleep endoscopy?
over diagnosis
• Pulse oxymetric measurements during sleep
For screening, watch over the patient while sleeping and hook the patient to a pulse oximeter then you can see if there is desaturation during the times the patient is developing a respiratory event
Just a screening tool, a very rough substitute to Nocturnal Polysomnography.
SLEEP APNEA MONITOR
• Diagnostic gold standard
This is what we call “Sleep Study”, the diagnostic gold standard.
You admit an OSAS suspect to a sleep laboratory, and they will hook the patient to monitor EEG, Oxygen saturation, Nasal Pressures, Esophageal Pressures
NOCTURNAL POLYSOMNOGRPAHY
For mild-moderate OSAS
Apply Dental Instruments to prevent the tongue from falling back during sleep.
Drawback – it only works for Mild-Moderate OSAS
• Oral appliances / Esmarch Occlusive Splint
o Therapeutic gold standard
For patients not directly treatable with surgery or medical management
• CPAP
o Therapeutic gold standard
For patients not directly treatable with surgery or medical management – Continuous Positive Airway Pressure – is gold standard.
By hooking the patient to a CPAP during sleep, the patient will continue to be oxygenated adequately even during the periods where the apnea occurs.
Pulmonologist usually calibrates the CPAP for individual, otherwise the patient may develop pneumothorax.
Most important diagnostic tool in maxillofacial trauma
CT scan with 3d reconstruction
Cannulating a salivary duct and injecting it with a dye to
check for patency of the duct or spillage of contrast on soft
tissue
Not necessary, except for certain circumstances (e.g
patient was hacked on the face and there’s possibility of
salivary ducts that were transected
Sialography
Treatment Priorities in maxillofacial trauma?
o “Facial injuries must not distract systemic
evaluation”
o CNS injuries
o Thoracic/abdominal injuries
o Facial soft tissue injuries
o Facial fractures
Facial fractures usually come last unless it’s lifethreatening
Closed vs semi closed reduction?
• Closed
Closed reduction is a procedure to set (reduce) a broken
bone without cutting the skin open. The broken bone is put
back in place, which allows it to grow back together. It works
best when it is done as soon as possible after the bone
breaks.
• Semi-closed
Make an incision in order to insert an instrument which
will be the one to interact with the bone. The incision
made here is not to expose the bone
ORIF vs OREF?
• Open, with internal fixation
An open reduction and internal fixation (ORIF) puts pieces of
a broken bone into place using surgery. Screws, plates,
sutures, or rods are used to hold the broken bone together
The things you use to aid in fixing/stabilizing the fracture will
be covered with the skin after the procedure
• Open, with external fixation
Appliances used to support/fix the fracture is visible
Most commonly fractured bone in the adult maxillofacial
skeleton
• Intimately related to the nasal septum
nasal bone
Blow to the nose is perpendicular to its axis = generalized depression to the nasal area. This kind of nasal bone fracture also involves the caudal end of the nasal septum. MOI?
Direct trauma
Hitting the nose at one side. The side where the hit fell will displace the nasal structure contralaterally
More common mechanism in nasal fractures
Right cross deformity
• Least commonly fractured bone in the maxillofacial skeleton
This area is not prominent.
Frontal sinus fx
S/SX of frontal sinus fx?
• Forehead depression — DIAGNOSTIC • Forehead swelling • Ipsilateral epistaxis • Sensorial changes • CSF Rhinorrhea Why will there be epistaxis? There will be blood accumulating in the frontal sinus and it's going to drain through the nose, that is why there is epistaxis.
• Second most commonly fractured bone in the maxillofacial skeleton
Mandibular fractures
Fractures in any other location in the mandible are always considered unfavorable or unstable. T or F?
T
S and sx of mandibular fracture?
- Malocclusion / Open-bite deformity — DIAGNOSTIC
- Palpable Step-Ladder Deformity — DIAGNOSTIC
- Abnormal Facial Contours
- Ecchymosis, Floor of Mouth
- Gingival laceration
- Pain, swelling & tenderness
- Intraoral bleeding
- Trismus
- Ear bleeding
Anatomic strengths of the mandible?
- Thickened U-shaped lower margin
* Various areas reinforced by crests and thickenings for muscle attachment
Anatomic weaknesses of the mandible?
- Incisive Fossa / Mental Foramen
- Impacted / unerupted teeth
- Cysts / abscesses
- Edentulousness
- Advancing age
- Angle & Condyle — poorly resistant to lateral forces
- Thin alveolar process
Diagnostics for mandibular fx?
- Conventional X-Rays: Mandibular AP— symphysis & parasymphysis
- Conventional X-Rays: Lateral Oblique — body & angle
- Conventional X-Rays: Modified Towne’s — condyles
- Conventional X-Rays: Panoramic view — most ideal
Initial immob for mandibular fractures?>
Figure of 8/ bartons bandaging
What reduction will be used in favorable fractures of the mandible as well as the body and condyles?
Closed Reductioin
What reduction will be used for unfavorable fractures of the mandible?
Open Reduction
• Constitute only 10-20% of all facial fractures.
• Most serious among all forms of facial fractures
Least common, but probably the most serious
MIDFACE FRACTURES
Low Palatal or Guerin Fracture
• 20-30%
• Results in a floating palate
the second most common
Separation of the hard palate from the maxilla. So you
have floating palate.
what le fort classi?
Le fort 1
• 35-55%
• Results in a floating maxilla
The most common
Separation at the area of pterygoid process, zygoma,
orbital floor, region of the bridge of the nose.
Pyramidal structure and will produce a floating midface.
what le fort?
LE FORT II
• 5-15%
• Results in a “dishpan” deformity
The most serious and probably sometimes lethal
The course of the blow to the face is so much that the entire facial skeleton will be disarticulated its attachments to the calvarium.
May be accompanied by intracranial injuries.
Fortunately, it’s also the least common.
Le fort 3
s/sx of what?
- Open-bite Deformity- “Gagged Bite”
- Massive facial edema
- Epistaxis
- Intraoral Bleeding
- Abnormal Facial Contours
- Sensorial Changes
- Upper Airway Obstruction
LE FORT FRACTURES (MID FACE FRACTURES)
s/sx of what?
- Open-bite Deformity- “Gagged Bite”
- Massive facial edema
- Epistaxis
- Intraoral Bleeding
- Abnormal Facial Contours
- Sensorial Changes
- Upper Airway Obstruction
LE FORT FRACTURES (MID FACE FRACTURES)
Drawer sign finding in lefort 1 2 and 3?
Le Fort 1: only palate is moving; Le Fort 2: palate and the nose is moving; Le Fort 3: the entire face is moving.
Treatment for le fort fx?
• Neurosurgical Evaluation/Clearance
Chances that px may have intracranial injuries
• Open Reduction with Internal and/or External Fixation
• Airway Maintenance
Always secure the airway
• AKA “TRIPOD” or “TRIMALAR” fracture
ZYGOMATICOMAXILLARY COMPLEX FRACTURES (CHEEKBONE)
ZYGOMATICOMAXILLARY COMPLEX FRACTURES (CHEEKBONE) involves fracture of the malar bone at 4 points
o Zygomaticomaxillary process
o Zygomaticofrontal process
o Zygomaticotemporal process
o Zygomaticosphenoid process
Pathognomonic sign for zygomaticomaxillary complex fx?
Cheek depression/loss of malar prominence
s/sx zygomaticomaxillary complex fracture?
- Cheek depression/loss of malar prominence• Enopthalmos/Hypopthalmos• Mucosal Ecchymosis near Zygomatic Buttress
- Diplopia
- Cheek numbness
- Ipsilateral epistaxis
- Trismus- in arch fractures
- Cheek swelling
Diagnostics zygomaticomaxillary fx?
Conventional X-Rays: Paranasal Sinus Series, Submentovertical View
• Computed Tomography with 3D reconstruction
tx for zygomaticomaxillary complex fx?
• “3point reduction with 2point fixation”
• Semi-close reduction (for isolated zygomatic arch fractures)
Gillies approach
• Open reduction
• Combined approach
describes a temporal incision (2 cm in length), made 2.5 cm superior and anterior to the helix, within the hairline. A temporal incision is made. Care is taken to avoid the superficial temporal artery.
Gillies approach
- Isolated fractures involving the orbital floor with sparing of the orbital rims
- Results from blunt eye trauma with prolapsing of the intraocular contents into the maxillary sinus.
Blow out fx
• Diplopia on upward gaze due to inferior rectus entrapment Cannot look up • Enopthalmos/Hypopthalmos • Ipsilateral epistaxis • Periorbital swelling • Orbital findings • Pain
s/sx of?
Blow out fractures
blow out fracture: what sign in conventional x ray upright waters view?
TEAR DROP” sign
to check for extraocular muscle entrapment
Used to differentiate a swollen orbit and an orbital entrapment
Forced duction test
both eyeballs are anesthetized and grasp the insertion of the inferior rectus muscle. Compare the mobility by grasping the muscle. If muscle is entrapped there will be restriction in the movement of the eyeball.
Forced duction test
Window period for facial fractures are?
2 weeks
- Different from an isolated nasal bone fracture
- Includes the nasal bone, ethmoid sinuses, frontal sinuses, medial canthus and anterior skull base.
- May be unilateral/bilateral
NASO-ORBITO- ETHMOIDAL (NOE) FRACTURES
Type 1 vs Type 2 vs Type 3 NOE fx?
- NOE I- uncomminuted fragment involving NOE complex
- NOE II- comminuted fracture of NOE complex, but with intact medial canthal attachments
- NOE III- severely comminuted fracture of the NOE with disruption of the medial canthal tendon
- Periorbital/medial canthal swelling
- Epistaxis
- Retruded/ impacted nasal complex
- Tecanthus
- (+) “Bow String” test
- Instability of medial canthus on palpation
s/ sx of >?
NOE fractures
is a palpebral anomaly that can be defined as an increased distance between the medial canthi. It may be unilateral or bilateral.
is produced by an abnormal insertion or length of the medial canthal tendons.
Telecanthus
the lid is pulled laterally while the tendon area is palpated to detect movement of fracture segments. A lack of resistance or movement of the underlying bone is indicative of a fracture.
Bow string test
