Ch 43 Objectives Flashcards
(426 cards)
1
Q
What is the function of the nasal cavity?
A
Filter, warm, and humidify inspired air.
2
Q
What are turbinates?
A
Highly vascular structures in the nasal cavity that can bleed during nasal intubation.
3
Q
What happens during nasal congestion?
A
Engorgement of mucosal veins leads to swelling of turbinate tissues, reducing nasal cavity space.
4
Q
What are sinuses?
A
Hollow, fragile bones that can leak cerebrospinal fluid (CSF) if traumatized.
5
Q
What is the pharynx?
A
A muscular tube extending from the nasal cavity to the esophagus, ending at C6.
6
Q
What are the three parts of the pharynx?
A
Nasopharynx, Oropharynx, and Laryngopharynx.
7
Q
What is the function of the pharynx in respiration?
A
Conducts air between the nasal cavity and larynx.
8
Q
What is the function of the pharynx in digestion?
A
Muscular constriction allows passage of food to the esophagus.
9
Q
What role does the pharynx play in phonation?
A
Acts as a resonating chamber for voice production.
10
Q
How does the pharynx assist in swallowing?
A
Respiration is reflexively inhibited by the medulla oblongata during swallowing to protect the airway.
11
Q
What is Waldeyer’s ring?
A
Lymphatic tissue encircling the oropharynx.
12
Q
What structures are included in Waldeyer’s ring?
A
Palatine tonsils, adenoids, base of tongue, and soft palate.
13
Q
What is the blood supply to the oropharynx?
A
External carotid, facial, and maxillary arteries.
14
Q
What can cause hypertrophy of tonsils/adenoids/uvula?
A
Often due to chronic infection, leading to airway obstruction, especially in children.
15
Q
What is a risk associated with tonsillectomy?
A
Close proximity to major vessels increases the potential for significant intraoperative/postoperative bleeding.
16
Q
What is the function of the epiglottis?
A
Located in the laryngopharynx; protects the vocal cords during swallowing.
17
Q
Is the epiglottis a passive structure?
A
No, its protective motion depends on superior elevation of the larynx.
18
Q
What increases the risk of aspiration related to the epiglottis?
A
Neuromuscular coordination is vital; nerve injury or rigidity increases aspiration risk.
19
Q
Which nerves control the swallowing reflex?
A
Glossopharyngeal (IX), Superior laryngeal nerve (branch of X), Recurrent laryngeal nerve (RLN, branch of X).
20
Q
What is the role of the nerves in swallowing?
A
They coordinate glottic closure and protect the airway from food/liquid aspiration.
21
Q
What are the three unpaired cartilages of the larynx?
A
Thyroid, cricoid, epiglottis.
22
Q
What are the three paired cartilages of the larynx?
A
Arytenoid, corniculate, cuneiform.
23
Q
What supports the larynx?
A
Hyoid bone.
24
Q
What is the primary function of the larynx?
A
Vocalization and speech articulation.
25
What is a secondary function of the larynx?
Airway protection and respiration.
26
What is the narrowest airway region in adults?
Rima glottidis (vocal cords).
27
What is the narrowest airway region in children under 10 years?
Traditionally considered to be the cricoid ring.
## Footnote
Historically led to preference for uncuffed ETTs in young children.
28
What are the benefits of Microcuff tubes for children over 8-10 years?
Improve seal, prevent subglottic edema, reduce postoperative complications (e.g., croup, stridor).
29
What is the function of the Facial Nerve (VII)?
Motor to facial muscles.
30
What is the function of the Trigeminal Nerve (V)?
Sensory to face, nasal cavity, palate; motor to mastication.
31
What is the function of the Glossopharyngeal Nerve (IX)?
Gag reflex; sensory to posterior tongue and pharynx.
32
What is the function of the Vagus Nerve (X)?
Includes SLN and RLN; controls vocal cords, airway reflexes.
33
What is the function of the Superior Laryngeal Nerve (SLN)?
Internal branch: sensory above cords. External branch: motor to cricothyroid (affects pitch).
34
What is the function of the Recurrent Laryngeal Nerve (RLN)?
Motor to intrinsic larynx muscles (except cricothyroid); sensory below cords. Injury → hoarseness or stridor.
35
Where is the Facial Nerve located?
Located at the tragus of the ear.
36
What does the Chorda tympani branch do?
Carries taste from the anterior 2/3 of the tongue and innervates submandibular and sublingual glands.
37
What are the branches of the Facial Nerve?
Anterior (4): Temporal, Zygomatic, Buccal, Mandibular; Inferior (1): Cervical; Posterior (1): Posterior Auricular.
38
What is the origin of the Trigeminal Nerve (Cranial Nerve V)?
Gasserian (trigeminal) ganglion
39
What are the divisions of the Trigeminal Nerve?
V1: Ophthalmic, V2: Maxillary, V3: Mandibular
40
What functions does the Trigeminal Nerve provide?
Provides sensory and motor innervation to the nose, sinuses, palate, and tongue. Aids in motor control of the face and in mastication.
41
What is the function of the Glossopharyngeal Nerve (Cranial Nerve IX)?
Motor & sensory innervation to the posterior 1/3 of the tongue, nasopharynx, and oropharynx.
42
What reflex does the Glossopharyngeal Nerve elicit?
Elicits gag reflex during stimulation of the posterior pharynx and vallecula.
43
What can stimulation of the Glossopharyngeal Nerve cause?
May cause bradycardia or gagging.
44
Where does the Superior Laryngeal Nerve (SLN) branch from?
Branches from the vagus at the hyoid level.
45
What is the function of the Internal branch of the SLN?
Sensory above vocal cords (to glottis) via thyrohyoid membrane.
46
What is the function of the External branch of the SLN?
Motor to cricothyroid (modulates pitch) via descends over the lateral thyroid cartilage to the distal trachea.
47
What is the path of the Recurrent Laryngeal Nerve (RLN)?
Ascends from the vagus up the distal trachea, passing through the cricothyroid ligament into the proximal trachea and vocal cords.
48
Where does the Recurrent Laryngeal Nerve (RLN) lie?
Lies between trachea and esophagus.
49
What is the motor function of the Recurrent Laryngeal Nerve (RLN)?
Motor to all intrinsic laryngeal muscles (except cricothyroid).
50
What are the sensory functions of the Recurrent Laryngeal Nerve (RLN)?
Sensory to trachea, larynx below vocal cords, and inferior surface of epiglottis.
51
How does the Recurrent Laryngeal Nerve (RLN) affect airway reflexes?
Affects vocal cord closure and sensory function up to the inferior aspect of the epiglottis.
52
What may epiglottic stimulation cause?
May cause bradycardia, bronchospasm, and hypotension via vagal reflex.
53
What is important to consider during intubation regarding the Recurrent Laryngeal Nerve (RLN)?
Requires careful handling during intubation, especially in pediatrics and patients with vagal hypersensitivity.
54
Cricothyroid Innervation and Function
Superior laryngeal nerve = Tension and elongates vocal cords
55
Thyroarytenoid Innervation and Function
Recurrent laryngeal nerve = Relaxes vocal cords
56
Vocalis Innervation and Function
Recurrent laryngeal nerve = Relaxes vocal cords
57
Posterior cricoarytenoid Innervation and Function
Recurrent laryngeal nerve = Abducts vocal cords
58
Lateral cricoarytenoid Innervation and Function
Recurrent laryngeal nerve = Adducts vocal cords
59
Transverse arytenoid Innervation and Function
Recurrent laryngeal nerve = Adducts vocal cords
60
Aryepiglottic Innervation and Function
Recurrent laryngeal nerve = Closes glottis
61
Oblique arytenoid Innervation and Function
Recurrent laryngeal nerve = Closes glottis; approximates folds
62
Sternohyoid Innervation and Function
Cervical plexus; C1, C2, C3 = Draws hyoid bone inferiorly
63
Sternothyroid Innervation and Function
Cervical plexus; C1, C2, C3 = Draws thyroid cartilage caudad
64
Thyrohyoid Innervation and Function
Cervical plexus; hypoglossal nerve; C1 and C2 = Pulls hyoid bone inferiorly
65
Thyroepiglottic Innervation and Function
Recurrent laryngeal nerve = Inversion of aryepiglottic fold
66
Stylopharyngeus Innervation and Function
Glossopharyngeal = Folds thyroid cartilage
67
Inferior pharyngeal constrictor Innervation and Function
Pharyngeal plexus; vagus = Aids swallowing
68
What can stimulate bradycardia during medical procedures?
Stimulating the glossopharyngeal or vagus nerve can cause bradycardia.
69
What should be approached with caution due to the risk of bradycardia?
Laryngoscopy or suctioning should be approached with caution.
70
What is a key strategy for securing an endotracheal tube (ETT)?
The ETT may need to be smaller and positioned away from the surgical field. Secure firmly using tape or suture, reinforced with transparent occlusive dressings.
71
What should be anticipated post-induction regarding airway access?
Difficult access may occur due to 90–180° head rotation, draping, suspension laryngoscopes, or retraction systems.
72
Why is pre-induction airway assessment crucial?
It is crucial for anticipating difficulty, planning for backup airway strategies, and selecting adjuncts or advanced devices.
73
What are the components of continuous ventilation assessment?
Use chest movement, auscultation, SpO₂, ETCO₂, and inspiratory pressures.
74
What sudden changes during ventilation may indicate problems?
Sudden changes may indicate cuff leak, tube obstruction/dislodgement, circuit disconnection, or ETT severance by surgical instruments.
75
What additional monitoring tools can be used for airway changes?
Precordial or esophageal stethoscopes are simple yet valuable tools for detecting subtle airway changes.
76
When is vigilance critical during surgery?
Vigilance is critical during table rotation, surgical field manipulation, and head repositioning.
77
What should be done to prevent complications during head rotation?
Extend IV lines, breathing circuits, arterial/CVP tubing, and pre-position large-bore IVs, arterial lines, and monitors on the side closest to anesthesia.
78
What should be done prior to turning the table?
Preoxygenate with 100% O₂ for 3–5 minutes, temporarily disconnect circuit and monitors to avoid tension-related trauma, and consider adding IV anesthetics.
79
What should be reassessed after bed movement?
Reconnect and immediately reassess tube position, breath sounds and chest expansion, SpO₂, ETCO₂, and anesthetic depth.
80
What positioning considerations are important for ENT cases?
ENT cases often require 360° head access by multiple surgical team members and head draped into the field, limiting access to ETT/circuit.
81
What should be prevented during ENT procedures?
Prevent inadvertent extubation, mainstem migration, and circuit disconnection.
82
What is important regarding padding during procedures?
Use padding to prevent pressure injuries at contact points.
83
How does table tilt affect BP readings?
Table tilt affects BP readings; account for hydrostatic gradient when using noninvasive cuff on the leg.
84
What may a surgeon perform in difficult or prolonged cases?
A surgeon may perform tracheostomy to allow secure airway and prevent ETT interference. Tracheostomy ETT is sutured and fixed in position.
85
Where should arterial lines or CVP be placed?
Place on the non-operative side or anesthesia-accessible side.
86
What should be considered for NIBP monitoring?
May use calf to prevent dampened IV flow in upper limbs.
87
What should be done for neuromuscular monitoring if hands are inaccessible?
Use tibial nerve and observe big toe flexion.
88
What should be considered for urinary output monitoring?
Consider Foley catheter for procedures longer than 3 hours or significant fluid shifts.
89
What is the purpose of a Heat Moisture Exchanger (HME)?
HME reduces insensible water loss during long procedures.
90
What are standard ETT considerations?
Standard ETTs with straight or flexible connectors are commonly used. Tube diameter and length affect airway seal and ventilation efficiency (small tubes = ↑ resistance, ↓ ventilation). Smaller-diameter ETTs distribute cuff pressure more evenly, reducing tracheal injury.
91
What are RAE Tubes?
RAE Tubes (Ring-Adair-Elwyn Tubes) have a preformed bend (oral or nasal) that prevents kinking and keeps the tube away from the surgical field.
92
What is the ideal use for Oral RAE Tubes?
Oral RAE Tubes are ideal for cleft palate repair, tonsillectomy, UPPP, and upper face/eye surgery.
93
What is the ideal use for Nasal RAE Tubes?
Nasal RAE Tubes are ideal for maxillofacial surgery, oral cavity procedures, and cosmetic facial surgeries.
94
What should be verified with RAE Tubes?
Must verify proper tube tip position—preformed shape may place tip too proximal/distal, risking endobronchial intubation.
95
What is a caution regarding Nasal RAE Tubes?
Avoid nasal RAE or NG tube placement in facial trauma patients due to the risk of intracranial penetration.
96
What is advisable pre-op in facial trauma?
CT head review is advisable pre-op in facial trauma.
97
What are Armored or Reinforced ETTs?
Armored or Reinforced ETTs contain a metal or plastic coil embedded in the wall, making them flexible and kink-resistant while maintaining shape during neck flexion or extreme angles.
98
What are the uses of Armored or Reinforced ETTs?
Useful in skull base surgery and posterior neck procedures.
99
What is a caution for Armored or Reinforced ETTs?
Even edentulous patients may occlude these tubes with oral tissues.
100
What are Laser-Resistant ETTs?
Laser-Resistant ETTs contain metal or laser-reflective material to prevent airway fires during laser use (e.g., laryngeal papilloma excision).
101
What is special about the cuff of Laser-Resistant ETTs?
The cuff is filled with saline (absorbs laser energy) and is often mixed with methylene blue to detect cuff rupture.
102
What should not be used as a laser-safe alternative?
Do NOT use a wrapped standard ETT with tape as a laser-safe alternative—this increases flammability risk.
103
What is the Laryngeal Mask Airway (LMA)?
The LMA can be used in pharyngeal surgery, as an intubation aid, and for airway rescue.
104
What are the advantages of using an LMA?
Advantages include no tracheal stimulation (reduced coughing on emergence), does not require neuromuscular blockade, and facilitates access to glottis, neurologic monitoring, and isolation of airway from pharyngeal bleeding.
105
What are the contraindications for LMA?
Contraindications include some laryngeal pathologies (e.g., tumors or obstruction).
106
What is the prevalence of local anesthetics in ENT surgery?
Local anesthetics are especially prevalent in nasal and sinus surgery.
107
How may local anesthetics be administered?
They may be used topically, via injection, combined with IV sedation, MAC, or general anesthesia.
108
What are the primary types of local anesthetic agents used?
Primarily amide-type agents, such as lidocaine and bupivacaine.
109
What is cocaine's role in ENT surgery?
Cocaine (4–10%) is used topically in >50% of rhinolaryngologic surgeries as a local anesthetic and potent vasoconstrictor.
## Footnote
Cocaine is metabolized by plasma cholinesterase, has a duration of ~45 minutes, and blocks catecholamine reuptake, leading to vasoconstriction and mucosal shrinkage.
110
What are the concentrations of vasoconstrictors like epinephrine used in local anesthesia?
Epinephrine is added in concentrations of 1:200,000 (5 mcg/mL), 1:100,000 (10 mcg/mL), and 1:50,000 (20 mcg/mL).
111
What are the benefits of using vasoconstrictors with local anesthetics?
They reduce systemic absorption of local anesthetics, maintain a higher concentration near nerve fibers, extend the duration of local anesthetic effect, and decrease plasma levels to lower the risk of systemic toxicity.
112
What caution should be taken when using cocaine and epinephrine together?
There is a risk of sympathetic overstimulation, leading to hypertension, tachycardia, and dysrhythmias. Avoid in cardiac patients and consider alternatives like oxymetazoline.
113
What is the preferred anticholinergic agent for intraoral surgeries?
Glycopyrrolate is preferred as it causes less tachycardia compared to atropine and does not cross the blood–brain barrier, resulting in no sedation.
114
What is a commonly used corticosteroid in ENT surgery?
Dexamethasone is commonly used.
115
What are the benefits of using corticosteroids in ENT surgery?
They reduce laryngeal edema, prolong local anesthetic analgesia, and decrease postoperative nausea and vomiting (PONV).
116
What is the mechanism of action of corticosteroids in surgery?
Corticosteroids reduce inflammation by inhibiting prostaglandins and histamine and decrease nociceptor sensitivity at surgical sites.
117
What caution should be taken when using corticosteroids?
They may suppress the immune response and mask infection.
118
What are the high-risk factors for postoperative nausea and vomiting (PONV) in ENT?
ENT procedures, especially middle ear and throat surgery, have a high incidence of PONV.
119
What mechanisms contribute to PONV in ENT surgeries?
Blood in the oropharynx is swallowed, leading to gastric irritation and emesis. Procedures like tonsillectomy are particularly high risk.
120
What preventive measures can be taken to reduce PONV?
Surgical packing in the throat to prevent blood drainage and ensuring the airway is suctioned, packs removed, and the patient is fully awake before extubation.
121
What is recommended for a multimodal antiemetic strategy?
It may include ondansetron, dexamethasone, scopolamine, etc.
122
What is the dose and notable feature of Cocaine?
4% solution = 3 mg/kgm; Only local anesthetic with vasoconstrictive ability; blocks reuptake of norepinephrine and epinephrine at adrenergic nerve endings
123
What is the dose and notable feature of Lidocaine?
4 mg/kg plain; 7 mg/kg with epinephrine 250-300 mg; Rapid onset; suitable for all areas of the tracheobronchial tree
124
What is a notable feature of Benzocaine?
Short duration of action (10 min); can produce methemoglobinemia
125
What is the dose and notable feature of Bupivacaine?
2.5 mg/kg plain; Slow hepatic clearance; long duration of action
126
What is the dose and notable feature of Mepivacaine?
4 mg/kg; Intermediate potency with rapid onset
127
What is the maximum dose and notable feature of Dyclonine?
300 mg maximum; Topical spray or gargle; frequent use for laryngoscopy, absorbed through skin and mucous membranes
128
What is Deliberate Controlled Hypotension (DCH)?
An anesthetic technique where mean arterial pressure (MAP) is intentionally lowered to reduce surgical bleeding, improve the visual field, and facilitate tumor resection or sinus endoscopy.
129
What are the characteristics of extensive head and neck tumor resections?
They may last up to 12+ hours and often involve major dissection, blood loss, fluid shifts, and hemodynamic instability.
130
How does controlled hypotension benefit endoscopic sinus surgery (ESS)?
Controlled hypotension improves surgical visibility in the narrow and vascular nasal/sinus field.
131
What is the target MAP for Deliberate Controlled Hypotension?
Avoid dropping MAP below 50–60 mmHg and do not exceed a 20% reduction from baseline.
132
What should be preserved during Deliberate Controlled Hypotension?
Cerebral autoregulation, renal perfusion, and coronary blood flow.
133
What special consideration is there for hypertensive patients during DCH?
Chronic hypertension shifts the autoregulation curve, and they may need a higher MAP to maintain organ perfusion.
134
What are the advantages of Sodium nitroprusside?
Potent, reliable, rapid onset and recovery, cardiac output well preserved.
## Footnote
Young adults: 1-5 mcg/kg/min; children: 6-8 mcg/kg/min. Possible side effects include reflex tachycardia, rebound hypertension, pulmonary shunting, and cyanide toxicity.
135
What are the effects of Dexmedetomidine?
Dose-dependent sedation and analgesia with associated hypotension, decreases intravenous/inhalational anesthetic requirements, smooth emergence.
## Footnote
Dosage: 1 mcg/kg over 10 min then 0.2-0.7 mcg/kg/hr. Bradycardia and hypotension are most often seen with bolus, heart block.
136
What is the dosage for Esmolol and its use?
200 mcg/kg/min to achieve a 15% reduction of mean arterial pressure.
## Footnote
Particularly useful to control tachycardia. Potential for significant cardiac depression.
137
What are the advantages of Nitroglycerin?
Preserves myocardial blood flow, reduces preload, preserves tissue oxygenation.
## Footnote
Adults: 125-500 mcg/kg/min; children: 10 mcg/kg/min. Increases intracranial pressure, highly variable dosage requirements.
138
What is the effect of Nicardipine?
Ca²⁺ channel blocker that preserves cerebral blood flow.
## Footnote
Dosage: 5 mcg/kg/min.
139
What is the combination of Remifentanil with Propofol?
Remifentanil: 1 mcg/kg IV then continuous infusion 0.25-0.5 mcg/kg/min; Propofol: 2.5 mg/kg IV, then infusion of 50-100 mcg/kg/min.
## Footnote
Remifentanil reduces middle ear blood flow, creating a dry surgical field for tympanoplasty. Propofol may help reduce PONV. No analgesic effect once remifentanil infusion is discontinued, postoperative secondary hyperanalgesia.
140
What types of radiation can laser light emit?
Laser light can emit infrared, visible, and ultraviolet radiation.
141
What are the benefits of using lasers in surgery?
Lasers provide precision cutting, minimal bleeding, and reduced tissue trauma/edema.
142
What are common uses of laser surgery in ENT?
Common uses include laryngeal tumor excision, tonsillectomies, and nasal and airway surgeries.
143
What are the properties and common uses of CO₂ Laser?
CO₂ Laser has a long wavelength, is absorbed by water, and has shallow penetration. It is preferred for laryngeal surgery due to high precision.
144
What are the properties and common uses of Nd:YAG Laser?
Nd:YAG Laser has a shorter wavelength and deeper tissue penetration. It is used for debulking tumors and coagulation.
145
What are the properties and common uses of Ho:YAG Laser?
Ho:YAG Laser is a pulsed IR laser, absorbed in water-rich tissues. It is used in tonsil and nasal surgeries.
146
What are the properties and common uses of Argon Laser?
Argon Laser emits blue-green light and is commonly used in ophthalmology and ENT.
147
What are the properties and common uses of KTP Laser?
KTP Laser uses potassium titanyl phosphate and emits green wavelength. It is used for soft tissue procedures, such as nasal polyps.
148
What does monochromatic mean?
One wavelength
149
What does coherent mean?
Oscillates in the same phase, or all the photons are moving in the same direction
150
What does collimated mean?
Parallel beam (focused, narrow)
151
What is the benefit of monochromatic, coherent, and collimated light?
This allows precise energy delivery with predictable tissue interaction
152
Why do airway fires happen?
Airway fires happen due to an oxygen-rich environment, the presence of combustible materials (ETT), and a laser beam ignition source.
153
What effect can positive pressure ventilation have during a laser strike?
Positive pressure ventilation during a laser strike can cause a blowtorch effect.
154
What is a prevention strategy for Airway Fire?
Use laser-resistant ETT, avoid N₂O, FiO₂ < 30%, fill cuff with methylene blue–dyed saline
155
What is the role of a saline-filled cuff in ETT Penetration?
Saline-filled cuff absorbs heat; dye signals leak
156
What should be avoided to prevent combustion in the reservoir?
Avoid air-filled cuffs; saline acts as fire suppressant
157
What type of goggles should be used for Nd:YAG lasers?
Use green lenses for Nd:YAG
158
What type of goggles should be used for KTP lasers?
Use orange-red lenses for KTP
159
What type of goggles should be used for CO₂ lasers?
Use clear lenses for CO₂
160
What is the prevention strategy for toxic smoke (plume)?
Use smoke evacuators at vaporization site—especially for viral papilloma or cancer
161
What should be adhered to in operating room policies?
Adhere to standardized laser safety protocols (fire drills, trained staff, visible signage)
162
What are the essential requirements for an Ideal Laser-Resistant Endotracheal Tube (ETT)?
Must provide ventilation, laser protection, and low fire risk.
163
What features should an Ideal Laser-Resistant Endotracheal Tube (ETT) have?
Metal wrapping or impregnation, and cuff inflation with saline + methylene blue.
164
What should be avoided when using standard ETTs?
Wrapping standard ETTs with reflective tape, as it is not effective and flammable.
165
What is the most common type of sinus surgery performed annually in the U.S.?
Endoscopic sinus surgery (ESS) – >250,000 performed annually in the U.S.
166
What are some conditions that may lead to recurrent sinusitis?
Nasal polyps, hoarseness, stridor, hemoptysis, tumors, trauma, vocal cord dysfunction, tracheal stenosis, foreign body aspiration.
167
What are some preoperative complications to consider for endoscopic sinus surgery?
Eye trauma, epistaxis, laryngospasm, bronchospasm, excessive plasma levels of local anesthesia and epinephrine.
168
What should be assessed during airway evaluation?
Obstruction, airway mass size/location, and review of imaging (CXR, CT, MRI).
169
What premedication is necessary for older children and adults with airway pathology?
Anxiolytic to prevent respiratory depression and worsening of airway obstruction.
170
What is the purpose of antisialagogues like glycopyrrolate?
To reduce secretions.
171
What should be considered for aspiration prophylaxis?
H2 blockers, prokinetics, antacids.
172
What is the common method for awake intubation?
An awake oral/nasal intubation with minimal sedation and topical anesthesia of the oral cavity, pharynx, larynx, and nasopharynx.
173
What is a rare but safer alternative to awake intubation?
An awake tracheostomy with local anesthesia.
174
What is the goal of maintaining anesthesia during shorter ENT procedures?
To avoid patient movement and vocal cord movement, and to control sympathetic nervous system response.
175
What is a microlaryngeal ETT (MLT)?
A cuff that is larger than small standard ETTs, allowing for a larger cuff distribution across the trachea.
176
What are the advantages of using a microlaryngeal ETT?
Secure airway, controlled ventilation, ETCO₂ monitoring, protects against debris.
177
What are the disadvantages of using a microlaryngeal ETT?
Possible interference with surgical field, risk of extubation, and laser-related complications.
178
What is the Intermittent Apnea Technique?
The anesthetist or surgeon removes the ETT, operates during a brief period of apnea, and then reintubates.
179
What are the risks associated with the Intermittent Apnea Technique?
Desaturation, reintubation difficulty, airway unprotected during apneic periods, vital sign lability.
180
What patient factors should be considered during anesthetic management?
Smoking exposure and alcohol use, which predispose to cardiovascular disease and labile vital signs.
181
What helpful agents can be used during anesthetic management?
Lidocaine, small doses of IV opioids (alfentanil, remifentanil, sufentanil, fentanyl), esmolol or dexmedetomidine.
182
What is essential for anesthesia management?
Adequate muscle relaxation of the vocal cords is essential for anesthesia management.
183
What should be used for brief muscle relaxation in short cases?
Use succinylcholine for brief relaxation.
184
What NMBs are recommended for longer cases (30 mins +)?
Use intermediate NMBs such as rocuronium, vecuronium, or cisatracurium.
185
What should be planned for by the end of longer cases?
Plan for the return of spontaneous respiration to meet extubation criteria.
186
What should be used if vocal cord monitoring is needed?
Use remifentanil infusion for immobility and reflex suppression.
187
What should be ensured during emergence and PACU?
Ensure thorough suctioning, humidified oxygen, and monitor for laryngospasm, post-extubation croup, and stridor.
188
When should extubation occur?
Extubate when the patient is awake with airway reflexes intact.
189
What is jet ventilation used for?
Jet ventilation is used in laryngeal surgery where ETT obstructs the surgical view.
190
How does jet ventilation work?
It involves a needle catheter delivering high-pressure O₂.
191
What are the risks associated with jet ventilation?
Maintaining oxygenation and/or CO2 elimination can be difficult in certain patients.
192
What patient risks are associated with jet ventilation?
Risks include morbid obesity, stiff thorax, advanced restrictive/obstructive lung disease, lung fibrosis, and reduced alveolar-capillary diffusion capacity.
193
What are the types of jet ventilation?
Types include supraglottic (above vocal cords), infraglottic (below vocal cords), transtracheal (through cricothyroid membrane), and via bronchoscope (inside rigid bronchoscope).
194
What is the mechanism of jet ventilation?
Inspiration involves a high-velocity gas jet forcing air into the lungs, while expiration is passive.
195
What is the jet pressure in jet ventilation?
Jet pressure can be up to 60 psi.
196
What safety measures should be taken during jet ventilation?
Use FiO₂ ≤ 30% to reduce fire risk, monitor chest rise, precordial stethoscope, and pulse oximetry.
197
What should be avoided during jet ventilation?
Use IV anesthetics only to avoid volatile agent leaks into room air.
198
What are the risks of air trapping/barotrauma in jet ventilation?
Incomplete exhalation can lead to increased airway pressure, resulting in pneumothorax or subcutaneous emphysema.
199
What can a misplaced jet lead to?
It can lead to gastric insufflation, hypoxia, or emphysema.
200
What causes poor expiration in jet ventilation?
Decreased pulmonary compliance and increased airway resistance in conditions like bronchospasm, obesity, and COPD.
201
When is jet ventilation contraindicated?
It is contraindicated in cases of full stomach, hiatal hernia, and trauma (unprotected airway).
202
What is THRIVE?
Transnasal Humidified Rapid-Insufflation Ventilatory Exchange.
203
What type of technique is THRIVE?
Noninvasive high-flow nasal oxygen technique.
204
What is the purpose of THRIVE?
Used to extend apneic oxygenation time in patients with minimal or absent respiratory effort.
205
What flow rate does THRIVE deliver?
Delivers humidified and warmed O₂ at high flows (10–12 L/min or higher).
206
What does THRIVE provide?
Passive oxygenation—prolongs safe apnea window.
207
What is a useful alternative to jet ventilation?
THRIVE.
208
Who is most commonly affected by foreign body aspiration?
Children <4 years.
209
What is a leading cause of accidental death among children under 4?
Asphyxiation by an inhaled foreign body.
210
What are leading causes of foreign body aspiration?
Nuts & seeds, small toys, hot dogs, bits of meat, coins.
211
Which bronchus is the most common site for foreign body aspiration?
Right bronchus due to vertical orientation.
212
What happens if the patient is supine during foreign body aspiration?
Gravity causes the object to enter the right upper lobe bronchus.
213
What happens if the patient is upright during foreign body aspiration?
The foreign body is more likely to settle in the right lower lobe.
214
What are common clinical presentations of foreign body aspiration?
Wheezing, coughing, choking, aphonia, tachycardia, cyanosis.
215
What should you suspect if sudden respiratory distress occurs?
Aspiration.
216
What tools are used for diagnosis of foreign body aspiration?
CT, flexible/rigid bronchoscopy, virtual bronchoscopy.
217
What remains the gold standard for diagnosis and treatment of foreign body aspiration?
Rigid bronchoscopy.
218
What does anesthetic management depend on?
Location of airway, size of object, and obstruction severity.
219
What is the recommended approach for an object in the larynx?
Direct laryngoscopy + Magill forceps under topical anesthesia.
220
What is the recommended approach for an object in the distal airway/trachea?
Spontaneous breathing induction with inhalation agent + rigid bronchoscopy.
221
What should be considered for severe obstruction?
Awake tracheostomy or rigid bronchoscopy in OR.
222
What should you prepare for if there is a full stomach?
Prepare for RSI and complete occlusion risk.
223
What should be avoided before securing the airway?
PPV.
224
What position should be used to reduce airway compromise?
Sitting position.
225
What medications should be pre-medicated with to decrease secretions?
Antisialagogues (e.g., glycopyrrolate), H2 antagonists, Metoclopramide.
226
How should ventilation be managed via rigid bronchoscope?
Via rigid bronchoscope side port (watch for leaks).
227
What should be avoided during instrumentation with the rigid bronchoscope?
Coughing, bucking, or straining.
228
What anesthesia technique is preferred for rigid bronchoscopy?
Total IV Anesthesia (TIVA) preferred.
229
What are the benefits of using TIVA?
Cardiovascular stability, allows quick titration, minimizes airway stimulation.
230
What type of oxygen should be used during anesthesia?
100% O₂.
231
What should be avoided to prevent contamination during anesthesia?
Volatile agents.
232
What are some airway complications?
Laryngospasm, bronchospasm, tracheal/bronchial laceration.
233
What are some respiratory complications?
Hypoxia, hypercarbia, barotrauma, pneumothorax, pneumomediastinum.
234
What are some cardiac complications?
Hypoxic cardiac arrest, dysrhythmias, vagal stimulation from head extension.
235
What are some mechanical complications?
Dental trauma, lip/gum injury.
236
What are some neurologic complications?
Hypoxic brain injury from inadequate ventilation.
237
What type of edema may occur?
Laryngeal or subglottic swelling (may last ≥24 hrs).
238
What should be ensured before extubation?
Return of consciousness and protective airway reflexes.
239
What should be used postoperatively as needed?
Humidified oxygen, racemic epinephrine, steroids, and bronchodilators.
240
What should be considered if significant airway edema occurs?
Postoperative intubation and sedation.
241
What may help assess airway patency before extubation?
Cuff leak test.
242
What are common procedures in anesthesia for face, ear, head, and neck?
Myringotomy with tube insertion, tympanoplasty, mastoidectomy, stapedectomy, acoustic neuroma.
243
What are the key concerns in anesthesia for these procedures?
1. Nerve preservation 2. Effect of nitrous oxide (N₂O) on middle ear pressure 3. Hemostasis (bloodless surgical field) 4. Prevention of postoperative nausea and vomiting (PONV).
244
Which nerves are commonly monitored during these procedures?
Facial nerve (CN VII), vagus (CN X) and recurrent/inferior laryngeal nerves (CN X), spinal accessory nerve (CN XI).
245
What monitoring techniques are used for nerve monitoring?
Electromyography (EMG), brainstem auditory-evoked potentials, electrocochleography.
246
What is the guidance for using muscle relaxants?
Only for induction/intubation, then avoid to preserve nerve responses.
247
What is the guidance for using local anesthetics?
Contraindicated; avoid at nerve sites as they suppress EMG signal amplitude.
248
What is essential for movement prevention during procedures?
Use opioid infusions (e.g., remifentanil, sufentanil).
249
What is the guidance regarding volatile agents and N₂O?
Acceptable with caution; discontinue N₂O before middle ear closure.
250
What is the role of midazolam preoperatively?
Helps assure amnesia and rapid emergence.
251
What is the middle ear?
An air-filled cavity housing 3 ossicles: malleus, incus, and stapes, connected to the nasopharynx by the eustachian tube.
252
What are common adult surgeries in this context?
Tympanoplasty, stapedectomy, mastoidectomy, ossiculoplasty.
253
What are common pediatric surgeries?
Myringotomy with tube insertion, tympanoplasty, grommet insertion, cochlear implants.
254
What are the anesthesia techniques used?
General anesthesia with LMA or ETT; ETT preferred if head turning/extension needed. Local + sedation requires a still, cooperative patient.
255
What is a primary problem at the beginning of surgery?
Pain from multiple injections of local anesthetic with epinephrine.
256
What can increase patient comfort during procedures?
Topical lidocaine and prilocaine (eutectic mixture of local anesthetics [EMLA]).
257
What should be avoided after intubation for facial nerve monitoring?
Neuromuscular blockers.
258
What is the approach to PONV prevention?
Use multimodal antiemetic prophylaxis and avoid agents that increase inner ear pressure (e.g., N₂O near case end).
259
What are techniques to reduce bleeding?
Head elevation (15–20°), avoid venous obstruction, normocapnia, controlled hypotension (SBP 80–90 mmHg or ↓ 20% of baseline MAP).
260
What pharmacologic agents can help achieve a bloodless field?
Volatile anesthetics, beta-blockers (labetalol, esmolol), α2-agonists (dexmedetomidine), opioids (remifentanil), magnesium sulfate.
261
What should be considered during emergence and recovery?
Avoid coughing, straining, or bucking to prevent prosthesis displacement and minimize postoperative bleeding.
262
What is the typical postoperative care for the head?
Head is typically bandaged postoperatively.
263
What should be ensured during emergence?
Smooth emergence with airway reflexes intact.
264
What is the solubility of Nitrous Oxide (N₂O) compared to nitrogen in blood?
N₂O is 34 times more soluble than nitrogen in blood.
265
How does N₂O affect middle ear pressure when the eustachian tube is obstructed?
N₂O enters faster than nitrogen leaves, increasing middle ear pressure.
266
What effect can positive pressure ventilation have on middle ear pressure?
It can further elevate middle ear pressure by forcing gas through the eustachian tube.
267
What is the effect of N₂O during tympanoplasty when the middle ear is open?
N₂O has no significant effect.
268
What are the potential consequences of using N₂O after tympanic membrane graft placement?
Continued use can increase pressure and cause graft displacement, leading to serous otitis media, stapes disarticulation, and impaired hearing.
269
What is the guideline regarding N₂O use during tympanoplasty?
Avoid N₂O entirely to prevent pressure shifts that could displace grafts.
270
What should be done if N₂O is used during tympanoplasty?
Discontinue N₂O ≥15 minutes before graft placement to allow middle ear pressure to normalize.
271
Why should N₂O be avoided in high PONV-risk patients?
N₂O increases PONV, which is already high in ear surgery.
272
What is the purpose of myringotomy?
To equalize pressure by making a small incision in the tympanic membrane.
273
What are the indications for myringotomy?
Relief of middle ear pressure/fluid due to chronic serous otitis media or recurrent otitis media.
274
What is the goal of myringotomy surgery?
To ventilate the middle ear and prevent hearing loss, speech delay, or permanent ear damage.
275
Is premedication usually needed for myringotomy?
Usually not needed, as it may outlast the procedure.
276
What is the preferred induction method for myringotomy?
Mask induction with sevoflurane + O₂ ± N₂O.
277
What is the maintenance practice for anesthesia during myringotomy?
Continue volatile agent (e.g., sevoflurane); N₂O is allowed due to tympanic membrane opening.
278
What airway management is recommended for uncomplicated cases?
Use mask or LMA.
279
What should be considered for postoperative care regarding antibiotics?
Antibiotics and steroids should be given in the external auditory canal.
280
What is typical regarding emergence after myringotomy?
Rapid emergence is typical; airway reflexes return quickly.
281
What is the PONV risk after myringotomy?
Low; but antiemetics may be used based on history.
282
When are most patients discharged after myringotomy?
Most patients are discharged within 1–2 hours post-op.
283
What is a tonsillectomy and adenoidectomy?
A common pediatric procedure, also performed in adults with OSA or UPPP.
284
What forms Waldeyer’s ring?
The tonsils, adenoids, and lingual tonsils, which can obstruct the airway when hypertrophied.
285
What are the airway challenges during tonsillectomy and adenoidectomy?
Shared airway requires coordination with the surgeon; risks include obstruction, laryngospasm, and post-extubation stridor.
286
What may displace or compress ETT/LMA during surgery?
Mouth gag (open mouth & tongue retraction) may displace or compress ETT/LMA; always reassess tube position after insertion.
287
What is the preferred airway device for pediatric, uncomplicated cases?
LMA or cuffed ETT.
288
What is the preferred airway device for patients age >8–10 years?
Cuffed ETT with leak at 20 cm H₂O to reduce postop edema & croup.
289
What is the preferred airway device for OSA or severe obstruction?
ETT with general anesthesia is often preferred.
290
What may high-risk adults (e.g., severe OSA) require?
May require awake fiberoptic intubation.
291
What is the induction method for pediatric patients?
Mask induction with sevoflurane + O₂ ± N₂O, with parents at bedside if needed for separation anxiety.
292
What are the maintenance goals during tonsillectomy and adenoidectomy?
1. Deep anesthesia to blunt airway reflexes. 2. Stable hemodynamics. 3. Rapid return of protective reflexes. 4. Minimize bleeding. 5. Reduce PONV.
293
What techniques are used for maintenance during surgery?
Volatile agents (e.g., sevoflurane), modest opioids, IV acetaminophen, dexmedetomidine, and antiemetics (dexamethasone + ondansetron).
294
What should be avoided due to a black box warning?
Codeine, due to ultrarapid metabolizers leading to morphine toxicity.
295
What are common surgical techniques for tonsillectomy and adenoidectomy?
Cold steel, cautery, coblation, snare, hot knife.
296
What is the recommended head position during the procedure?
Head turned 45–90° away from anesthesia provider.
297
What is the average blood loss during tonsillectomy?
Approximately 4 mL/kg or ~5% of blood volume.
298
What are the indications for considering transfusion?
Clinical instability, lab derangements, underlying anemia or comorbidity.
299
What is the most serious complication postoperatively?
Postoperative bleeding, which can lead to persistent vomiting, poor oral intake, and desaturation.
300
What can cause PONV in postoperative patients?
Swallowed blood, opioids, pharyngeal stimulation.
301
What are the best practices for emergence and extubation?
Consider deep extubation to avoid coughing/bucking; use 2% lidocaine spray to minimize laryngospasm.
302
What is the recommended position for children postoperatively?
Tonsil position (side-lying, head down).
303
What is the recommended oxygenation method postoperatively?
100% humidified O₂ by face tent or mask.
304
What should be ensured before patient discharge?
Patient must be fully awake with intact reflexes.
305
What is the pain management recommendation postoperatively?
IV acetaminophen, avoid codeine, consider NSAIDs.
306
When should a patient be admitted postoperatively?
If <3 years, OSA, comorbidities, bleeding, desaturation, vomiting, or poor intake.
307
What is Posttonsillectomy Hemorrhage (PTH)?
Most common emergency pediatric airway surgery.
308
What are the higher risk factors for PTH?
Patients >15 years, male gender, history of recurrent tonsillitis, and electrocautery techniques > cold dissection.
309
What percentage of PTH cases occur within 6 hours post-surgery?
~75% of cases.
310
What percentage of PTH cases occur between 6–24 hours post-surgery?
~25% of cases.
311
What is the likelihood of PTH occurring up to Day 6 post-surgery?
Less common, but possible.
312
What is the more common clinical presentation of PTH?
Slow oozing > profuse bleeding.
313
What symptoms may swallowed blood cause?
Nausea and vomiting, and may obscure airway visualization.
314
What are signs of hypovolemia in PTH?
Tachycardia, hypotension, restlessness/agitation.
315
What should be assessed in PTH cases?
Always assess hemodynamics and history.
316
What labs are needed for preoperative preparation?
Hemoglobin & hematocrit, coagulation profile.
317
What is the first step in resuscitation for PTH?
Restore volume first: IV fluids and blood products before induction if needed.
318
What is the induction method for anesthesia in PTH?
Rapid Sequence Induction (RSI).
319
What positioning is recommended during induction?
Slight Trendelenburg (head-down) to protect trachea & glottis from aspiration.
320
What intubation options are available for PTH?
RSI is standard; awake intubation may be necessary in certain patients.
321
What are the indications for awake intubation?
Full stomach, unstable hemodynamics, compromised airway anatomy or massive bleeding.
322
What is the purpose of gastric decompression in intraoperative management?
Assess blood loss, reduce aspiration risk.
323
What is essential for suction setup during surgery?
May need multiple suction lines.
324
What should be ready for transfusion during surgery?
Crossmatched blood and fluids.
325
What is the goal for airway protection during emergence and recovery?
Extubate only after full return of protective airway reflexes.
326
What should be confirmed before reversal/extubation?
Confirm surgical hemostasis.
327
How should PONV be managed post-surgery?
Treat aggressively due to risk of aspiration from swallowed blood.
328
What are the indications for thyroid surgery?
Thyrotoxicosis (e.g., Graves' disease), thyroid malignancy (most commonly papillary or follicular), and large goiters causing airway compression.
329
What are the surgical approaches for thyroid surgery?
Open, minimally invasive, or robotic-assisted. A thyroidectomy is performed as definitive treatment for thyrotoxicosis or malignancy.
330
What is the anatomical location of the thyroid gland?
Butterfly-shaped gland, anterior to the trachea and just below the larynx; connected by thyroid isthmus.
331
What is the size and vascularity of the thyroid gland?
Largest endocrine gland (20 g) and extremely vascular (blood flow is ~5× gland weight).
332
What nerves are in close proximity to the thyroid gland?
Intrinsic Recurrent laryngeal nerve (RLN) controls vocal cord movement and external branch of superior laryngeal nerve controls pitch modulation.
333
What complications may arise from injury to the recurrent laryngeal nerve?
Injury may result in airway obstruction post-extubation.
334
What conditions can be exacerbated by excess thyroid hormone (T3/T4)?
Tachyarrhythmias, hypertension, and thyroid storm.
335
What is thyrotoxicosis?
Excess circulating thyroid hormone (any cause).
336
What is hyperthyroidism?
Thyrotoxicosis due to increased thyroid production.
## Footnote
Most common cause of thyrotoxicosis: Graves' disease.
337
What is the principal treatment for thyroid malignancies?
Surgery for excision of the tumor and staging.
338
What percentage of thyroid malignancies are well differentiated?
Most thyroid malignancies (>90%) are considered well differentiated and categorized as papillary thyroid cancer (PTC) or follicular thyroid cancer (FTC).
339
What is the prognosis for papillary thyroid cancer (PTC)?
PTC accounts for 70% - 80% of thyroid cancer, usually presents at an early stage, and has an excellent prognosis (>95% 10-year survival).
340
What is the prognosis for follicular thyroid cancer (FTC)?
FTC accounts for 10% of thyroid cancer and tends to present at a later stage than PTC. (10-year survival rate for FTC is 85%).
341
What are the primary goals of thyroid surgery?
1. Ensure euthyroid state 2. Evaluate airway anatomy and function 3. Assessment of end-organ complications.
342
What labs and imaging are used in thyroid surgery evaluation?
TSH, Free T4, T3, CBC, electrolytes, EKG for arrhythmias if symptomatic or elderly, CXR/CT Neck if goiter or suspected tracheal compression.
343
What medications should be continued on the morning of surgery?
Antithyroid drugs (e.g., methimazole, PTU), beta-blockers (e.g., propranolol for symptom control), and steroids (may need stress dose in hyperthyroid patients treated with glucocorticoids).
344
What are the anesthetic implications of hyperthyroidism?
Increased β-adrenergic activity leads to tachycardia, arrhythmias, and increased oxygen demand. There is a higher incidence of myasthenia gravis and sensitivity to muscle relaxants, necessitating reduced NMBA dosing. There is also a risk of thyroid storm, which is rare but potentially life-threatening.
345
What potential airway issues are associated with hyperthyroidism?
Normal airway exam does not rule out obstruction. Large goiters may compress or deviate the trachea, cause tracheomalacia, or narrow the airway lumen, making ventilation or intubation difficult.
346
What should be included in the pre-induction assessment for hyperthyroidism?
Examine the airway in a supine position, check for voice changes, dysphagia, and stridor. Consider CT neck/chest and bronchoscopy if significant compression is noted.
347
What is the management for a normal airway in hyperthyroidism?
Use rapid sequence induction (RSI) or standard induction with endotracheal tube (ETT).
348
What should be done in case of tracheal compression or goiter?
Consider awake fiberoptic intubation.
349
What is the risk associated with tracheomalacia?
There is a risk of airway collapse after extubation, which may require delayed extubation or tracheostomy.
350
What anesthetic technique is recommended intraoperatively for hyperthyroidism?
General anesthesia with ETT is recommended.
351
What should be avoided regarding nerve monitoring during surgery?
Avoid long-acting neuromuscular blockers to allow intraoperative EMG monitoring of the recurrent laryngeal nerve (RLN) and superior laryngeal nerve.
352
What is the preferred vasopressor for hypotension in hyperthyroid patients?
Use direct-acting agents like phenylephrine.
353
What are the most common postoperative complications following thyroid surgery?
The most common complications are hypocalcemia, RLN damage, and hematoma at the surgical site.
354
What should be monitored postoperatively in hyperthyroid patients?
Monitor voice assessment, airway patency, signs of hematoma, and calcium levels for hypocalcemia.
355
What is the function of the Medtronic NIM 3.0 EMG Tube during thyroid surgery?
It monitors RLN and vocal cord function intraoperatively via electromyography (EMG) to help prevent RLN injury.
356
What are the advantages of the NIM 3.0 ETT?
It allows the surgeon to identify the muscles innervated by the RLN prior to traction or severing the nerve.
357
What positioning is recommended for patients during anesthesia management?
Supine with neck extension (Rose position), head elevated ~30° with a roll under shoulders, arms tucked, and ulnar nerves padded.
358
What should be avoided to protect EMG integrity during surgery?
Do not use long-acting neuromuscular blockers, lidocaine on cords, or indirect vasopressors like ephedrine.
359
What is the cause of hypocalcemia due to parathyroid injury?
Inadvertent removal, devascularization, or stunning of the parathyroid glands during thyroidectomy.
360
What is the pathophysiology of hypocalcemia?
Decreased parathyroid hormone (PTH) leads to decreased serum calcium and increased neuromuscular excitability.
361
When does hypocalcemia typically onset postoperatively?
Typically appears 24-96 hours postoperatively.
362
What are mild to moderate symptoms of hypocalcemia?
Perioral numbness, paresthesias, abdominal pain, carpopedal spasm, mental status changes.
363
What are severe symptoms of hypocalcemia?
Laryngospasm, tetany, seizures, cardiac arrest, prolonged QT interval.
364
What is Chvostek sign?
Facial twitching when tapping over the facial nerve.
365
What is Trousseau sign?
Carpal spasm with BP cuff inflation.
366
How is symptomatic hypocalcemia treated?
10 mL of 10% calcium gluconate or calcium chloride IV over several minutes, continuous infusion of calcium at 1–2 mg/kg/hr.
367
What is the incidence of recurrent laryngeal nerve (RLN) injury?
Occurs in up to 14% of cases.
368
What is the presentation of unilateral RLN injury?
Ipsilateral vocal cord paralysis (cord remains midline) leading to hoarseness and weak voice.
369
What is the presentation of bilateral RLN injury?
Both cords remain midline leading to glottic obstruction, stridor, aphonia, and respiratory distress post-extubation.
370
What is the anesthesia management for unilateral RLN injury?
Monitor voice; typically non-emergent.
371
What is the anesthesia management for bilateral RLN injury?
Requires immediate intervention, including emergent reintubation or tracheotomy.
372
What is the cause of neck hematoma as an airway emergency?
Postoperative bleeding compressing the airway.
373
What are early signs/symptoms of neck hematoma?
Neck swelling or pressure, neck pain.
374
What are severe signs/symptoms of neck hematoma?
Dyspnea, stridor, asphyxiation, rapid airway compromise.
375
What is the management for neck hematoma?
Surgical emergency requiring immediate evacuation of hematoma.
376
What is the prevalence of cleft palate and cleft lip?
One of the most common congenital craniofacial anomalies (~1:700 births).
377
What are the components of clefts?
Clefts may involve lip, hard palate, soft palate, or a combination.
378
What is the surgical timing for cleft lip repair?
Repair at ~3 months (with tip rhinoplasty).
379
What is the surgical timing for cleft palate repair?
Repair at 5–8 months to support normal speech development.
380
What is the 'Rule of 10s' for cleft repair?
Age >10 weeks, weight >10 lb, hemoglobin >10 g/dL, WBC <10,000.
381
What are airway considerations for cleft palate repair?
Difficult intubation risk due to cleft anatomy; pack cleft with gauze to prevent blade slippage.
382
What are postoperative considerations for cleft repair?
Tongue-lip suture often placed to prevent obstruction; avoid oral airways post-repair.
383
What are indications for dental restoration under anesthesia?
Extensive dental disease, developmental delay, cerebral palsy, Down syndrome, or behavioral non-cooperation.
384
What should be evaluated for airway management in dental restoration?
Small mouth, large tongue, high secretions, enlarged tonsils, atlantoaxial instability, congenital heart disease.
385
What are common indications for sinus and nasal surgery?
Chronic sinusitis, nasal polyps, deviated septum, facial fractures, chronic environmental and drug allergies.
386
What anesthesia techniques are used for sinus and nasal surgery?
Local ± sedation, or general anesthesia; vasoconstriction is essential to control bleeding.
387
What should be done prior to extubation in sinus and nasal surgery?
Remove all packing prior to extubation; suction stomach to reduce PONV.
388
What are airway threats in facial/neck trauma?
Edema, bleeding, fractures (nasal/oral), lacerations, foreign bodies (avulsed teeth, blood clots, bone fragments), disruption of nasal passages or pharynx.
389
What is the first step in airway strategy for trauma?
Assess C-spine (7 cervical vertebrae must be visualized).
## Footnote
C7 is the most common site of traumatic fx.
390
What must be suspected with a cervical injury?
Vertebral artery injury must be suspected because these fractures can lead to vertebral artery tear or occlusion.
391
What are alternative airway strategies?
Fiberoptic intubation, retrograde wire placement, cricothyrotomy, jet ventilation, or awake tracheostomy.
392
What are trauma red flags?
Blistering/burns around mouth/nose (early intubation), Le Fort II & III fractures (avoid nasal intubation), suspected basal skull fracture (nasal instrumentation contraindicated).
393
What characterizes a Le Fort I fracture?
Horizontal maxillary fracture extending from the floor of the nose and hard palate, through the nasal septum, and through the pterygoid plates posteriorly. Generally safe for oral/nasal intubation.
394
What characterizes a Le Fort II fracture?
Pyramidal fracture from the bridge of the nose involving orbit beneath the zygoma, and through the lateral wall of the maxilla and the pterygoid plates. Risk of cribriform plate injury; avoid nasal ETT.
395
What characterizes a Le Fort III fracture?
Totally separates the midfacial skeleton from the cranial base, traversing the root of the nose, the ethmoid bone, the eye orbits, and the sphenopalatine fossa. Avoid nasal ETT due to risk of intracranial entry.
396
What are the ABCs in maxillofacial and orthognathic surgery?
Airway, breathing, circulation.
397
What should be prepared for during maxillofacial surgery?
Difficult airway due to edema, limited mouth opening, facial deformities or dental appliances.
398
When is nasal ETT preferred?
When intermaxillary fixation (IMF) is planned.
399
What are signs of a basal skull fracture?
CSF rhinorrhea, blood behind tympanic membrane, periorbital edema, 'raccoon eyes.'
400
What are the risks of nasal intubation in basal skull fractures?
Inadvertent intracranial placement of ETT/NGT leading to meningitis or brain injury.
401
What are preferred airway approaches in difficult situations?
Tracheostomy under local anesthesia or awake oral intubation.
402
What should be evaluated during C-spine and trauma assessment?
Cervical spine injury, subdural hematoma, pneumothorax, and intra-abdominal bleeding.
403
What are key practices for managing small mouth opening?
Pain: responds to short-acting opioid or midazolam; Mechanical: may require alternative intubation strategy.
404
What should be available at the bedside for IMF procedures?
Wire cutters.
405
What should be done during emergence from anesthesia?
Fully awake extubation with intact airway reflexes; suction thoroughly and verify ETT position after mouth gag removal.
406
What does orthognathic surgery include?
Sagittal split osteotomy (mandible) and Le Fort osteotomies (maxilla).
407
What are common concerns in radical neck dissection?
Nutritional concerns due to tumor-related dysphagia, prior radiation effects, and airway risks.
408
What types of flaps are used in surgery?
Regional pedicle flaps (pectoralis major myocutaneous flap, trapezius flap, forehead rotational flap) and free tissue transfer (microvascular flaps).
409
What is the goal of vascular access during surgery?
Maintaining stable hemodynamics, supporting microvascular perfusion, avoiding vasoconstriction, overhydration, and hypoperfusion.
410
What are recommended lines for monitoring?
Arterial line for continuous BP + ABG monitoring, Foley catheter for fluid and urine output monitoring, CVP line (avoid internal jugular vein).
411
What should be avoided in anesthesia maintenance?
Depolarizing muscle relaxants if nerve monitoring is in use.
412
What is crucial in fluid management?
Avoid fluid overload; maintain euvolemia especially in hypovolemic, malnourished, or dehydrated patients.
413
What are the steps for airway management during surgical procedures?
Advance ETT to just above tracheal incision, remove ETT only after new airway is secure and ventilation is confirmed.
414
What are the anesthetic steps for intraoperative tracheostomy or laryngectomy?
Patient should be fully oxygenated before tracheal incision; suction the airway to clear secretions and blood.
415
What may carotid sinus manipulation cause?
Vagal reflexes such as bradycardia, hypotension, and cardiac arrest.
416
What are some preventative strategies for carotid sinus manipulation?
Local anesthetic to carotid sinus and anticholinergics (e.g., glycopyrrolate or atropine).
417
What is the risk associated with venous air embolism (VAE)?
VAE risk is due to head-up position and open neck veins.
418
How can venous air embolism be detected?
Using precordial Doppler or transesophageal echocardiography (TEE).
419
What is critical in the event of a venous air embolism?
Immediate aspiration of air via central venous pressure (CVP) line.
420
Why is ICU admission recommended postoperatively?
Due to fluid/electrolyte shifts, altered ventilation-perfusion dynamics, and long anesthetic duration.
421
What complications should be monitored postoperatively?
Tracheostomy care, laryngeal edema, flap congestion, and pulmonary issues like pneumothorax, hemothorax, and pulmonary edema.
422
What is the risk associated with surgical wounds?
Hematoma risk with potential for airway obstruction, requiring emergent evacuation if present.
423
What happens to the reinforced tube at the end of the case?
It is typically exchanged for a tracheostomy cannula.
424
What is the recommended agent selection for anesthesia maintenance?
Inhalational agents plus supplemental opioids (e.g., remifentanil).
425
What should be avoided after intubation if nerve monitoring is needed?
Depolarizing agents.
426
What type of vasopressors should be used for hypotension?
Direct-acting vasopressors (e.g., phenylephrine) rather than indirect ones (e.g., ephedrine) due to catecholamine stimulation risk.
