question

What is CN V1? What does it innervate?

answer

Opthalmic division of trigeminal nerve (anterior ethmoidal nerve) - (sensory). Innervates: skin on forehead, upper eyelid, dorsum of nose

question

What is CN V2? What does it innervate?

answer

Maxillary divisionof trigeminal nerve (sphenopalatine nerve) (sensory). Innervates skin of lower eyelid, upper cheek, side of nose, upper lip.

question

What is CN V3? What does it innervate?

answer

Mandibular division of trigeminal nerve (lingual nerve) (motor & sensory). Innervates: Muscles of mastication, tensor muscles, skin of lower cheek, temporal region, mandible, lower lip, anterior 2/3 of tongue (sensory).

question

What is CN IX? What does it innervate?

answer

Glossopharyngeal nerve (somatic sensory, motor, special sensory (taste), parasympathetic, visceral sensory) Innervates: Stylopharyngeus m., Posterior 2/3 of tongue (taste and sensory), parotid gland, mucosa of pharynx, carotid body and sinus). Branches: Tympanic n., Lesser petrosal n.

question

What is CN X? What does it innervate?

answer

Vagus nerve (somatic sensory, special sensory - taste, parasympathetic, visceral sensory) Innervates laryngeal mucosa above vocal cords (inferior epiglottis) (sensory and mm of Larynx, most mm of Pharynx and palate, epiglottis, thoracic & abdominal viscera) Major Branches: Recurrent laryngeal, Superior laryngeal (internal and external), espophageal plexus, Anterior & Posterior Vagal Trunks

question

What is the SL branch of CN X? What does it innervate?

answer

Superior laryngeal branch of the vagus nerve Innervates Cricothyroid muscles (External branch).

question

What is the IL branch of CN X? What does it innervate?

answer

Internal laryngeal nerve of vagus nerve (sensory) Innervates laryngeal mucosa above vocal cords (inferior epiglottis)

question

What is the RL branch of CN X? What does it innervate?

answer

Recurrent laryngeal nerve of vagus nerve (motor) Innervates: Laryngeal mucosa below vocal cords.

question

If anesthesia is light and pressure is put on the Vagus nerve what will happen?

answer

Vagal response (pt. will brady down)

question

What are the branches of CN VII? What does it innervate?

answer

Facial Nerve (somatic sensory, special sensory - taste, parasympathetic) Innervates: muscles of facial expression, anterior 2/3 of tongue (taste), lacrimal gland, submandibular gland, sublingual gland) Branches:Posterior Auricular, Temporal, Zygomatic, Buccal, Marginal Mandibular, Cervical, Corda Tympani (taste), Greater Petrosal

question

With respect to the shared airway, what information do you need to discuss with the surgeon prior to the procedure?

answer

Table position Tube size Oral or Nasal airway or trach? Tube out which side? Type of ventilation (vent vs Jet)

question

What are the specific concerns with respect to monitoring the airway when it is shared in ENT surgery?

answer

Adequacy of ventilation Disconnects Leaks Extubation

question

What kind of airway monitoring should be done in ENT cases?

answer

VIGILANCE!!! ETCO2 Machine Alarm

question

What are the unpaired cartilages of the larynx?

answer

Thyroid Cricoid epiglottis

question

Name the paired cartilages of the larynx

answer

Arytenoid Corniculate Cuneiform

question

Name the function of the Oblique arytenoids (muscles)

answer

Approximates aryepiglottic folds, narrows inlet

question

Name the function of the aryepiglottic muscle

answer

Narrows inlet

question

Name the function of the Thryoepiglottic muscle

answer

Widens inlet by pulling aryepiglottic folds apart

question

Name the action of the cricothyroid muscle

answer

Tenses vocal cords, tilts cricoid and arytenoids posteriorly

question

Name the action of the thyroarytenoid muscle

answer

Relaxes vocal cords, pulls arythnoids forward

question

Name the action of the Vocalis muscle

answer

Relaxes vocal cords, pulls arythnoids forward

question

Name the function of the lateral cricoarytenoid

answer

Adducts vocal ligaments

question

Name the action of the posterior cricoarytenoid

answer

Abducts vocal ligaments

question

Name the action of the transverse arytenoids

answer

Closes posterior part of rima glottis

question

Describe pre-op airway assessment for ENT cases

answer

Absolutely imperative (normal airway assessment) History of tumor needs careful assessment

question

What kind of specialized ETT are available for ENT surgeries?

answer

Regular RAE (preformed) NIM-EMG (assesses recurrent laryngeal n.) Anode, armored, reinforced, kant kink (used when they are moving the airway around during surgery - ACDF) Laser shielded Carden or Mon-jet tubes (jet ventilation) Intubating or Fast Trak LMAs for VC observation Cuffs-LVHP, HVLP, self-inflating foam, automatic regulating, or no cuff

question

What is the smallest area in the airway for a child under 8-10 years old?

answer

Cricoid

question

What is the smallest area in the airway for a child above the age of 8-10 yrs old (and an adult?)

answer

Glottis

question

When should children be switched to a cuffed tube?

answer

Age 8-10

question

What can happen with a high pressure, low volume cuff?

answer

Ischemia

question

Why are local anesthetics used in ENT surgeries?

answer

Patients don't like pain and helps with blood loss

question

What are the thre advantages and 1 disadvantage to mixing amides and esters together?

answer

Quicker onset Longer duration Less toxic May reduce effectiveness

question

What is the concentration, dose, and notable features for ENT procedures for cocaine?

answer

Concentration: 4% Dose: 3 mg/kg Only local anesthetic with vasoconstrictive ability. Blocks reuptake of norepi and epi at adrenergic nerve endings.

question

What is the concentration, dose, and notable features for ENT procedures for lidocaine?

answer

Concentrations: 2%, 4%, 2% viscous, 10% aerosol, 2.5 ; 5% ointment, 10%, 15%, 20% Dose: 4 mg/kg plain; 7 mg/kg with epi, 250-300 mg Rapid onset, suitable for all areas of the tracheobronchial tree

question

What is the concentration, dose, and notable features for ENT procedures for benzocaine?

answer

Concentrations: 0.25%, 0.5%, 0.75% Dose: 2.5 mg/kg plain Slow hepatic clearance, long duration of action

question

What is the concentration, dose, and notable features for ENT procedures for mepivacaine?

answer

Concentrations: 1%, 2% Dose: 4 mg/kg Intermediate potency with rapid onset

question

What is the concentration, dose, and notable features for ENT procedures for dyclonine?

answer

Concentrations: 0.5%, 1% Dose: 300 mg maximum Topical spray or gargle, frequent use for laryngoscopy, absorbed through skin and mucous membranes

question

What is the advantage of adding vasoactive drugs to local anesthetics?

answer

The airway is lined with highly vascularized mucous membranes. Addition of vasoconstrictors to LA decreases bleeding.

question

What is the same dose of epi?

answer

1.5 mcg/kg or 200 mcg

question

What kind of procedures is cocaine frequently used for?

answer

rhinolaryngologic procedures

question

Why is cocaine frequently used for rhinolaryngologic procedures?

answer

Great vasoconstrictor Duration of action 45 min Blocks reuptake of norepi

question

What medication should you be cautious with when used with epi?

answer

Cocaine

question

What are the advantages of using anticholinergics for ENT procedures (3)?

answer

Antisialogogue Helps decrease vagal tone Bronchodilator

question

Which anticholinergics cross the BBB?

answer

Atropine and scopalamine

question

Which anticholinergic does not cross the BBB?

answer

Glycopyrrolate

question

Why is glydopyrrolate a good choice of anticholinergic to use in ENT procedures?

answer

Does not cross the BBB - no sedation

question

Name 3 advantages to giving corticosteroids for ENT procedures.

answer

Decrease laryngeal edema Helps prevent PONV Prolongs analgesic effect of LA

question

How do corticosteriods work?

answer

Inhibit prostaglandin production

question

What is a disadvantage to using corticosteroids in ENT procedures?

answer

Immunosuppression

question

Which corticosteriod is most commonly used in ENT procedures? How long does it last? When is it contraindicated?

answer

Dexamethasone (lasts a couple of days - don't use if already immunosuppressed)

question

Why is PONV incidence high in ENT procedures?

answer

Pt swallows blood Anesthesia effects Surgical trauma to ear

question

What are some disadvantages to PONV

answer

Prolongs recovery time Patient is uncomfortable Discharge is delayed

question

What are some interventions that can help to minimize PONV in ENT procedures?

answer

Steriods **Adequate IV fluids 5HT3 Agonists H1 blockers Scopalamine patch Droperidol Pain Control Alcohol under nose Propofol or TIVA

question

What is deliberate controlled hypotension? Why is it used in ENT procedures?

answer

Reducing MAP to some predetermined level related to the limits of cerebral and systemic autoregulation (usually > 60 mmHg) to minimize blood loss (highly vascular sites) and because of long surgical times.

question

How is deliberate controlled hypotension accomplished?

answer

Type of anesthetic (propofol/remi infusion common) Titratible IV drip Adjust anesthetic or IV drip according to MAP Use A-line for close BP monitoring Assess individual patient for appropriate MAP value (60 mmHg in health patient)

question

When is jet ventilation (HFJV) used in ENT surgery?

answer

In laryngeal surgery when an ETT would be in the way or ESWL (lithotrypsy for kidney stones)

question

How is jet ventilation done?

answer

A metal needle is either attached to the operating laryngoscope or is simply passed through the vocal cords. It is either manually actuated or attached to a JV machine. High pressure blows air into the lungs for ventilation (chest does not move). High RR are used (100 or higher)

question

What type of anesthesia is used with Jet Ventilation?

answer

TIVA

question

What safety precautions are used with Jet Ventilation?

answer

Low O2 concentrations to prevent fires Monitor adequacy of ventilations (SPO2); (Check movement, auscultation, SPO2) Observe for complications

question

What are some complications of Jet Ventilation?

answer

Barotrauma SQ emphysema Pneumothorax

question

What is the advantage to the surgeon in using laser surgery for ENT procedures?

answer

Very precise excision Less tissue damage Less bleeding

question

What are the common laser types and what is the difference between them?

answer

CO2, Nd:YAG, Argon Different wavelengths for different effects

question

What can be done with lasers in surgery?

answer

Thermal effects Can cut, coagulate, and vaporize tissue

question

What are the primary safety concerns (4) with laser surgery?

answer

Eye protection - wear the glasses Airway fires - prevent, recognize, and treat Plume contaminants - wear special masks, suction Use ETT that are made for laser surgery

question

What are the Safety Guidelines for Lasers?

answer

Post warning signs outside OR Protect patient's eyes Matte-finish black instruments Lowest O2 concentration possible Avoid N2O (supports combustion) Place lasers in standby when not in use Use ETT specifically for lasers Inflate cuff with normal saline Shield adjacent tissues with wet gauze Suction plume

question

What is nerve preservation?

answer

Surgery of the head and neck where the surgeon will need to isolate and determine the function of each nerve as he proceeds with electrical stimulation.

question

What should the anesthetic plan include in cases that require nerve preservation

answer

Patient should not be paralyzed. Volatile anesthetics also cause muscle relaxation. Opioids with low dose volatile anesthetics are a good choice (provides nerve integrity allowing for better assessment.

question

What will nitrous do to air filled cavities?

answer

Air filled cavities will expand if possible. Nitrous will diffuse into air filled cavities faster than the bloodstream can absorb nitrogren because nitrous is more soluble than nitrogen.

question

What is the function of the Eustachian tube?

answer

The inner ear is vented through the Eustachian tube when yawning or moving the jaw.

question

What is the result of nitrous and ear surgery?

answer

It will increase inner ear pressure - not good with tympanoplasties - avoid nitrous.

question

Why is control of bleeding every important in ENT procedures?

answer

Surgeons are often working in tiny areas under microscopes. Even a small amount of bleeding is bad.

question

What are some interventions that can be done to reduce bleeding in ENT procedures (5)?

answer

Use ephendrine-containing solutions Mild head elevation will decrease venous pressure Reducing BP with increased anesthesia or hypotensive techniques. Reduce incidence of coughing and bucking May want to extubate deep

question

Name 6 common procedures for the face and ear.

answer

Myringotomy Tympanoplasty and mastiodectomy Parotidectomy Cleft lip and palate TMJ surgery Dental restoration

question

Describe Myringotomy and Tubes procedure (M;T) and anesthesia considerations.

answer

Usually done on infants and small children. Done under microscope, tympanum incised, tube placed. Can be accomplished with mask anesthesia. 5 min duration unless doing tonsillectomy also Sevo and nitrous and oxygen IV not necessary most of the time Head will need to be turned from side to side for surgeon access

question

Describe the Tympanoplasty and Mastoidectomy procedure and anesthesia considerations.

answer

Performed for performations and sholesteatoma Tympanic membrane is reconstructed Mastoid bone that is involved is removed and usually a tympanoplasty will need to be done Working with a microscope - bleeding and movement are concerns No nitrous Can be done with an LMA but you have limited access to the head Sometimes done under local

question

Describe the Parotidectomy procedure and anesthesia considerations.

answer

Unilateral facial surgery. Multiple important structures in the area. Surgeon will want to test integrity of the branches of the facial nerve with a nerve stimulator. No paralysis after intubation. Limited access to ETT, secure it properly. May be prolonged surgery, pad appropriately. Preoperatively assess facial movement. Table will be turned.

question

Describe the TMJ procedure and anesthesia considerations.

answer

Pre-op airway assessment!! Open or arthroscopic procedure Nasal intubation preferred, surgeon may want to manipulate interorally.

question

Describe TMJ.

answer

Internal derangement with closed lock or painful clicking, arthritis, hypermobility, fibrous ankylosis, chondromalacia, synovitis, and arthralgia.

question

What are some post-op complications associated with TMJ procedure?

answer

V, VII, and VIII CN deficits, intraoral edema from saline infusion during arthroscopy --> don't extubate until edema goes away!

question

Describe the Cleft Lip and Palate procedure and anesthesia considerations.

answer

Usually on infants, may be malnourished. Incidence of heart disease also. If extensive defect done in stages. May have difficulty intubating if scope falls into cleft. Use oral RAE or flexible ETT, secured to mouth properly. Tongue tip has suture and taped to cheek

question

What should be given to help with airway edema in Cleft Lip and Palate procedure?

answer

Steriods

question

What should be observed carefully post-op in Cleft Lip and Palate?

answer

Airway

question

Describe Dental Restorations procedure and anesthesia considerations.

answer

Performed for rampant caries, trauma on uncooperative or handicapped patients. Nasal intubation is usually required. Afrin and K-Y lubrication important. Parents/caregiver often accompanies patient to OR. Pre-op sedation or 'brutane', either way a challenge Deep extubation less traumatic.

question

What are some anesthesia issues involving handicapped patients?

answer

Can be uncooperative. Can have multiple other disorders (heart disease, epilepsy, autism, etc) May have difficult airway (Pierre-Robin) Parent/caregiver often accompanies pt. to OR

question

Name some common procedures of the throat.

answer

Tonsils and adenoids. Bleeding tonsils (bring back) Endoscopies: Laryngoscopy, Esophoscopy, Bronchoscopy, Panendoscopy UPPP

question

What are indications for removing tonsils and adenoids?

answer

Recurrent tonsillitis, airway obstruction (snoring), or recurrent otitis media, mostly children, some adults (adults recover poorer and longer).

question

What are some anesthesia concerns for removing tonsils and adnoids (T;A)?

answer

Degree of airway obstruction Shared airway Mouth gag Intubation and Extubation concerns Pain Management Need for rapid awakening

question

What is the anesthetic considerations for tonsils and adenoid (T;A) removal procedure?

answer

Assess patient pre-op to determine how to proceed IV vs. inhalation induction Procedure = 20-40 min Steroids for post-op edema ; nausea Antisialogogue

question

What is the anesthetic procedure for T;A procedure for children?

answer

Inhalation induction with volatile, nitrous, and O2 Intubation under deep inhalational or with short acting NDMR Start IV for emergency and meds Protect eyes, table turned Provide deep anesthesia for stimulation

question

What are considerations with respect to the ETT and the T;A procedure?

answer

RAE ETT Tube secured with mouth gag or tape Airway suspended with the mouth gag - neck extended and shoulder roll used for access. ETT should have 20 cm leak to prevent edema (croup). Shared airway - always watch tube!

question

How should the patient be extubated after T;A?

answer

Extubate deep or awake after gentle suctioning.

question

What complication will occur if there are secretions on the vocal cords following a T;A procedure and how should it be treated?

answer

Laryngospasm. Treat with positive airway pressure - Succs if that does not resolve it.

question

How should be patient be transported after T;A procedure?

answer

Transport on patient's side with head down a little.

question

What are some post-op considerations following the T&A procedure?

answer

Pain meds for post-op pain relief Watch for bleeding (excessive swallowing)

question

What is bleeding tonsil?

answer

Rare complication of T&A but can happen at post-op day 7

question

What are the anesthetic concerns & procedure for treating bleeding tonsil?

answer

Treat as full stomach - intubate using RSI Have suction on and near by Patient is usually very apprehensive May be volume depleted, prepare to give fluids and/or blood. Try to replace volume pre-op Pass NGT to suction blood from stomach

question

Why are endoscopies done?

answer

Tumors, foreign bodies, biopsies, papillomas, tracheal stenosis, VC dysfunction

question

How are endoscopies performed (equipment)?

answer

Using a rigid or flexible scope (rigid scopes are suspended) Consider smaller ETT or jet ventilation.

question

What are some complications of endoscopies?

answer

Eye trauma (surgeons) Patients (laryngospasms, bronchospasm)

question

What are some concerns with regard to airway and endoscopies?

answer

May have varying degrees of airway obstruction or access. Manage airway stimulation with depth of anesthesia. Aspiration prophylaxis, antisialogogue Consider awake intubation with anesthetized airway Shared airway Adequate suction prior to extubation Manage airway stimulation with depth of anesthesia May need intermittent apnea; watch SPO2 & communicate. Proper muscle relaxation for good visualization for surgeon.

question

What post-op considerations are there for endoscopy procedures?

answer

Observe in PACU for signs of airway edema and obstruction. Consider steroids for edema prophylaxis.

question

What s Uvulopalatopharyngoplasty (UPPP)?

answer

Procedure for the relief of obstruction of the airway seen in patients with Pickwickian syndrome or OSA.

question

What is the pathophysiology for OSA?

answer

Patients are usually obese with redundant pharyngeal tissue --> airway challenges. OSA --> with long standing decreased O2 and increased CO2, increased airway resistance --> pulmonary vasoconstriction, pulmonary artery increased BP --> right heart failure (cor pulmonale)

question

If the patient has a very severe condition of OSA what procedure may need to be done before doing the UPPP?

answer

A tracheostomy under local anesthesia before inducing GA

question

What are some anesthesia considerations with the UPPP procedure?

answer

Consider an antisialogogue. If airway appears sufficient, IV induction, RSI using oral RAE tube. Similar set-up as the tonsil Table turned to the surgeon

question

What are some post-op considerations following UPPP?

answer

Adult patients prefer semi or high flowlers position in PACU to aid in ventilation. Make sure patient is awake enough to manage his own airway. Caution with post-op ncarcotics - surgeon will likely use LA.

question

What are the major face and neck surgeries?

answer

Maxillofacial trauma & orthognathia surgery (LeFort I, II, III and other orthognathia surgeries) Radical neck dissection Laryngectomy Tracheostomy

question

With nasal fractures and cribriform plate fractures what must you be cautious with?

answer

Inserting NGT - Contraindicated!!! Do not nasally intubate La Fort III (possibly not II).

question

What should you assess and be thinking about with respect to La Fort and Cririform fractures?

answer

All fractures are potential airway problems Signficant form is needed for fx - other injuries? La Fort II, III - disruption of cribriform plate possible Soft tissue edema and hematoma of airway Blood debris may be in the airway Assess carefully. CSF in nose or ears? Do not nasally intubate La Fort III, possibly not II If emergent - oral intubation or trach with LA In ER - ABC's first In the OR - may be intubated already. If not nasal ETT for La Fort I and possibly for II is best.

question

What are some considerations for intubating a patient for an orthognatic procedure?

answer

BSSO, Le Fort I, II moves the maxilla or mandible forward or backward Nasal ETT requested by surgeons Prepare nasal passage with vasoconstrictor (Afrin) and plenty of lubrication (may try placing a nasal trumpet while waiting for relaxant)

question

What are some post-op considerations for orthognatic procedures?

answer

Patient frequently has mouth wired shut at end of case Has to be awake and in control of airway before extubation with scissors handy to cute wires or band. Blood loss can be extensive - large bore IV. Steroids for edema of the airway.

question

What are some basic considerations with regard to Radical Neck Dissection/Laryngectomy?

answer

Usually for cancer, most often heavy drinkers/smokers for many concerns - watch liver disease and drug doses. Thorough pre-op assessment including talking with the surgeon regarding extent of tumor Reconstriction can occur at same time or later (myocutaneous flaps, reconstruction of bowel). May start out with trach - use reinforced tape. Consider are and CVP lines, possibly Swan-ganz

question

What are specific anesthetic concerns for Radical Neck?

answer

Surgeon will want to stimulate nerves. Limit NMB. May have significant blood loss. Use large bore IV, manage fluids accordiing to CVP, colloids/blood. May have to replace blood Surgeon may request hypotensive technique If doing a laryngectomy, trach may be performed in middle of case - you will assist. Stimulation of carotic sinusmay cause decreased HR Consider complications VAE, TEE, throboembolim, airway edema, fluid shifts. Will not be extubated sooon --> to ICU

question

Describe the Tracheostomy procedure and anesthetic implications.

answer

Probably under LA by surgeon If planned, nerve blocks can be performed to anesthetize the airway. Expect coughing/bucking. Will assist with the airway. If already intubated will be directed to pull ETT to just above tracheal incision until surgoe secures trach Highly simulating, may be benzos or narcos

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