Anesthesia for ENT surgeries Flashcards by Hannah Garrison

Unique challenges for ENT surgeries include

use of specialty equipment- lasers, endoscopes, special ET tubes
use of specialized anesthetic/ventilation techniques
often have a preexisting tenuous airway- tumors, abscesses, congenital disorders
increased risk of airway fire
share airway with surgeon- access to patient is limited or nonexistent

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The four cranial nerves that supply sensory & motor function to the airway include

trigeminal, glossopharyngeal, facial, & vagus

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The trigeminal nerve provides

sensory innervation to the face

Three divisions include: ophthalmic, maxillary & mandibular

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The glossopharyngeal nerve provides sensory innervation to

posterior 1/3rd of the tongue
oropharynx
vallecular
anterior epiglottis

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The glossopharyngeal nerve is responsible for the afferent limb of the

gag reflux

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The facial nerve is located at the

tragus of the ear

-supplies motor and sensory function to the face for facial expressions

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The six major branches of the facial nerve include:

“The zebra bit my cousin paul”

anterior: temporal, zygomatic, buccal, & mandibular
inferior: cervical
posterior: posterior auricular

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The vagus includes the

superior laryngeal nerve (internal & external branch)

Recurrent laryngeal nerve

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The internal branch vs. external branch of the superior laryngeal nerve.

internal branch- sensory innervation to posterior epiglottis to vocal cord folds
external branch- motor innervation below the vocal cords

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The recurrent laryngeal nerve provides

sensory innervation below the vocal cords & trachea
motor innervation to all intrinsic laryngeal muscles
-Right RLN loops under subclavian artery
L RLN loops under aorta & susceptible to injury

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There is increased ______ in the head & neck

vascularity

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Facial, head, & neck arteries include:

carotid (internal & external)
facial 
maxillary
superficial temporal
deep temporal
superior thyroid
buccal
middle meningeal

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Facial, head & neck veins that are deep include

internal jugular
maxillary
vertebral

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Facial head and neck veins that are superficial include

external jugular
superficial temporal
occipital
facial

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Sharing of the airway requires

preparation
planning
communication

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For ENT cases, preoperative airway assessment

is critical
a thorough history & extensive evaluation allows:
-deliberate approach to airway management
-need for additional equipment & assistance
-determine alternative approaches

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Common considerations for ENT cases nclude:

true sharing of the airway with the surgeon- eye protection, tube placement must allow for surgical facilitation (down-sizing)
-head of bed often rotated 90 to 180 degrees- need for additional line & tubing length (HME device)
Arms tucked- second IV line, nerve monitoring
-precordial or esophageal stethoscope

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Nerve monitoring requires

specialized ETT

short acting narcotics & lack of paralysis

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ETT needs to be secured with

tape or suture to prevent extubation, disconnects & leaks

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After turning the patient,

ALWAYS REASSESS
-oxygenation/anesthetic level- tube placement, breath sounds
IV access

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Specialized ETT tubes include:

small diameter ETT- decreased ventilation & increased resistance; standard tubes may result limited cuff contact
Oral ring, Adair, & RAE tubes- allows for better surgical access
-armored and reinforced tubes- greater flexibility and resist kinking (not guaranteed)
-metal-impregnated- reduce occurrence of airway fire
-laryngeal mask airway (LMA)

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Common drugs for ENT cases include

vasoactive drugs
anticholinergics
corticosteroids
postoperative nausea & vomiting
deliberate controlled hypotension

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Vasoactive drugs include

epinephrine- causes vasoconstriction 1:200,000
cocaine- naturally occurring ester of benzoic acid
Combination of these drugs can result in: headaches, hypertension, tachycardia, & dysrhythmias

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Local anesthetics that might be used include

cocaine 4%
lidocaine 2%
bupivacaine 0.25%

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Anticholinergics may be used for

antisialogogue effects | reduce vagal tone- glycoyrolate preferred

Corticosteroids may be used to

reduce nausea & vomiting (given early) | inhibit production of prostaglandins reducing pain & edema

ENT surgeries associated with increased incidence of

PONV | particularly middle ear

Additional reasons for PONV with ENT surgery include

accumulation of blood in oropharynx & swallowed- throat pack, orogastric suctioning prior to extubation multimodal approach to prevent/treat

Select techniques commonly used in ENT surgery include:

laser surgery endoscopy jet ventilation foreign body aspiration

Deliberate controlled hypotension is a technique to

reduce blood loss in prolonged cases reduce MAP to pre-determined limits of cerebral autoregulation (50-60 mmHg; within 20% of baseline) -arterial line is required (not always) -better operating conditions achieved when hypotension is achieved with B-blocker

Laser light beams are used for their

thermal effect- lasers have only one wavelength

Commonly used lasers in ENT are:

CO2- longer wavelength- shallow depth & precise Nd:YAG (neodymium-doped yttrium aluminum garnett)- shorter wavelength- pass through superficial structures Argon

Laser safety includes

warning signs outside the OR eye protection- provider & patient, lens depends on laser being used use lowest oxygen concentration possible (goal of <30%) avoid nitrous oxide fill ETT cuff with saline and/or methylene blue laser "plume"

Most surgical fires occur during

head & neck surgery due to combination of oxygen & laser use laser penetrates ETT into oxygen rich environment- creates blowtorch effect

When an airway fire occurs, remove

ETT immediately and replace with a new tube | perform bronchoscopy

Prevention of airway fires includes

``` metal impregnated ETT saline filled ETT cuff use lowest FiO2 possible avoid nitrous oxide avoid paper drapes use water-based lubricants ```

Endoscopy procedures may include

panendoscopy, laryngoscopy, bronchoscopy, esophagoscopy (flexible or rigid scope), sinus surgery

Common pathology with endoscopy includes

foreign body aspiration tumors/lesions vocal cord dysfunction

Anesthetic considerations for endoscopy include:

manage brief periods of extreme stimulation- avoid patient movement- consider lidocaine, remifentanil, and esmolol to block sympathetic stimulation short procedures- careful muscle relaxation constantly sharing airway with surgeon- small cuffed ETT 5.0-6.0 mm for adult, intermittent apnea

Jet ventilation is

manual ventilation using hand valve or mechanical device - inspiration is high velocity jet stream (60 psi) - expiration is passive

With jet ventilation, if an airway mass lies above the level of gas delivery, there is an increased risk of

air trapping resulting in subcutaneous emphysema or pneumothorax

Jet ventilation may require

TIVA anesthesia

Jet ventilation is contraindicated in

full stomach, hiatal hernia, trauma

High frequency jet ventilation is used when

limited access to the airway | - done through a small needle, ETT, catheter or side port to a rigid bronchoscope

High frequency jet ventilation uses

low tidal volumes & high respiratory rates

Maintaining________ can be difficult in certain patient populations with high frequency jet ventilation.

oxygenation

Indications for sinus surgery includes

``` sinus obstruction (infection, polyps, or tumors) sinustomies ```

Surgical options for sinus surgery includes

endoscopic (FESS) external flouro brain lab

Sinus surgery can be performed under

general anesthesia vs. MAC | -ETT vs. LMA (decreased risk of blood flowing in oropharynx)

Polyps associated with asthma & cystic fibrosis can result in

allergies | reactive airway

Goals with sinus surgery include to

decrease bleeding through mild hypotension, vasoconstrictor use, & deep anesthesia

Complications of sinus surgery include

dural puncture

Treatment for dural puncture includes

``` discontinue nitrous oxide (if using) ETCO2 25-30 mmHg mild hypotension place foley catheter consider mannitol 25-50 g/IV patch by surgeon ```

Sinus surgery can possibly indicate

deep extubation | would want to prevent coughing, bucking, and worsening of dural puncture if patient has one

The leading cause of accidental death among children <4 years is

foreign body aspiration

Most aspirated items are

food particles but can include beads, coins, pins, or parts of small toys

Signs & symptoms of foreign body aspiration includes

wheezing, coughing, aphonia, & cyanosis

The anesthetic management for foreign body aspiration depends on

size & location of object

If a foreign body is aspirated in the larynx, then use

laryngoscopy & removal with Magill forceps

If a foreign body is aspirated in the distal larynx or trachea, then use

rigid bronchoscopy with mouth guard to avoid injury | tracheal tears, & inadequate ventilation

Anesthetic considerations for foreign body aspiration includes:

inhalational induction with 100% oxygen- maintain spontaneous respiration administer antisialagogue, H2 blocker, & prokinetic coughing, bucking or straining must be avoided be cognizant of full stomach- RSI- full airway obstruction- surgeon must be prepared to perform cricothyrotomy or tracheotomy observe for vagal stimulation during procedure

Postoperative considerations for foreign body aspiration include

return of airway reflexes edema possible for up to 24 hours post procedure--> Cuff leak? supportive measures- racemic epinephrine, bronchodilators, steroids

Anesthesia for ENT surgeries Flashcards

(62 cards)