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James' final FRCA SOE > ENT/Airway > Flashcards

ENT/Airway Flashcards

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1
Q

Pathophysiology of stridor?

A

Indicates a reduction in airway diameter of >50%

Bernouilli principle - cross-sectional area of airway decreases, velocity of air increases creates low pressure in airway exacerbating airway collapse

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2
Q

Inspiratory vs expiratory stridor?

A

Inspiratory stridor = extrathoracic e.g. laryngeal obstruction (-ve pressure during inspiration worsens obstruction)

Expiratory stridor = intrathoracic (tracheobronchial obstruction) (+ve pressure during expiration reduces airway calibre)

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3
Q

Causes of acute stridor?

A

Foreign body aspiration
Infection - epiglottis, laryngitis, neck abscess
Vocal cord palsy (e.g. post head and neck surgery)
Anaphylaxis
Laryngotracheobronchitis

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4
Q

What are the immediate non-surgical options available for managing stridor ?

A
  1. HFNO - high FiO2, humidified, PEEP
  2. Nebulised adrenaline - 5-10mls of 1:1000, vasoconstrictor
  3. Steroid therapy - increase airway calibre, remember radius to 4th power resistance
  4. Heliox - reduces reynolds number, inc. laminar flow, reduce WOB but less FiO2
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5
Q

Advantages and disadvantages of awake fibreoptic intubation?

A

Awake fibreoptic intubation:
Advantages: keep pt. spont ventilating until airway secured, used when facemask ventilation or laryngoscopy likely to be v difficult (e.g. supraglottic lesions, base of tongue)

Risks: tumour may be difficult to anaesthetise, requires co-operation, difficult if pt. un-co-operative or in extremis, cork in bottle phenomenon

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6
Q

Advantages and disadvantages of awake videolaryngoscopy?

A

Advantages - allows passage of tube under direct vision, overcomes cork in bottle effect (when style/bougie removed)

Risks - requires co-operation, not suitable for base of tongue, poor MO, or supraglottic masses

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7
Q

Advantages and disadvantages of awake tracheostomy?

A

Cases where mask and intubation ventilation likely to be difficult/impossible

Patients required to lie flat, makes dyspnoea worse, may have difficult anatomy, requires ENT

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8
Q

Advantages and disadvantages of IV induction GA for difficult airway?

A

Advantages - may be only way if patient anxious/uncooperative, familiar technique for anaesthetists, can mitigate risks by pre-emptively passing cricothyroid cannula e.g. for jet
Can use HFNO for apnoeic oxygenation

Risks - risk ‘losing the airway’ as patient not spont ventilating therefore not oxygenating and ‘waking up’ risks significant hypoxia

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9
Q

Advantages and disadvantages of inhalational induction for difficult airway?

A

Advantages - historically technique of choice, theory is keeps pt. spont ventilating, and if they obstruct then no anaesthetic delivered and patient wakes

Risks - in practice, pharyngeal loss of tone results in worsening obstruction, volatile agent is unable to be expired and patient stays asleep. Need significant anaesthetic depth for airway instrumentation

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10
Q

How would you perform an ATI?

A

Pre-procedure:
- Indication
- Explanation of procedure
- Consent
- Choose best nostril
- Review FNE / CT images

Procedure:
- Positioning, Resus, IV access, Monitoring, Assistant, Drugs, Equipment
POSITION - pt sat up, facing patient
RESUS - drugs drawn up
IV access - secured
MONITORING - AAGBI standard monitoring
ASSISTANT - consider 2nd anaesthetist
DRUGS
- Resus
- Sedation, minto remi infusion or dexmedetomidine
- Lidocaine topicalisation
- Anti-siallogue
- Drugs for induction and maintanence, TIVA or volatile
EQUIPMENT
- Airway trolley including plan D
- Nasal rae tube if nasal intubation
- HFNO for apnoeic oxygenation

Nasal mucosa - co-phenelcaine
Oropharynx topicalisation 9mg/kg lidocaine toxicity, use 10%
20-30 sprays back of mouth
Can spray as go with 2% lidocaine + air, sprayed above and below cords
Get pt. to inspire, coughing is good when topicalising

Intubating trachea with scope, railroading tube, confirming within trachea above carina, confirming with ETCO2, drugs then inflate cuff

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11
Q

Name 4 anaesthetic considerations for an endoscopic resection of laryngeal carcinoma?

A
  1. Co-morbidities associated with smoking and alcohol (risk factors for L. cancer)
  2. Potential for difficult laryngoscopy
  3. Shared airway
  4. Potential for surgical laser use
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12
Q

2 ETTs used for laryngeal surgery?

A
  1. Microlaryngeal tube (MLT
    - 4.0-5.0mm PVC tube of adult length
  2. Flexometallic endotracheal tube (“reinforced tube”)
    - Available 3.0-9.5mm
    - Wire within tube allows it to bend without occluding lumen
  3. Laster resistant endotracheal tube
    - Double cuffed
    - Non-flammable
    - Flexible stainless steel tube
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13
Q

Disadvantages of conventional airways in laser surgery?

A
  • Narrow radius = high vent pressures
  • Need paediatric bougie
  • Position of tube in larynx can hinder surgical access
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14
Q

Name 3 tubeless techniques used in laser surgery?

A
  1. Spontaneous ventilation
    - Allows for assessing vocal cord
    - Low flow O2 with spont vent delivered narrow catheter
    - Difficult to maintain anaesthesia in adults
  2. Jet ventilation
    - Supraglottic - Transglottic - Transtracheal (cricothyroid)
    - Risk of barotrauma/breath stacking
    - Automatic or manual jet ventilator
  3. Apnoeic oxygenation
    - Unobstructed surgical field
    - High flow nasal O2 can extend apnoeic period to 10 minutes
    - Risks of hypercapnoea
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15
Q

Airway options in dental?

A
  1. Nasal mask
    - Spont breathing with sevo
    - Needs jaw thrust
    - Simple uncomplicated procedures
    - Needs pharyngeal pack
  2. LMA (usually flexi)
    - Longer procedures e.g. impacted teeth
    - Spont or controlled
    - Sometimes pharyngeal pacl
  3. ETT
    - Nasal vs. oral
    - Pharyngeal pack
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16
Q

4 year old with stridor - differential?

A

Croup (laryngotracheobronchitis)
Inhaled foreign body
Acute tonsilitis
Epiglottitis
Retropharyngeal abscess
Smoke inhalational injury
Trauma
Diphtheria
Angio-oedema

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17
Q

Epiglotittis - anaesthetic “how to”

A

Pre-operative:
Call for help - Consultant anaesthetist, Consultant ENT
Usually anaesthetic/paediatric history, exam (but do not distress child)
Avoid:
- Indirect laryngoscopy
- Lateral neck x-rays
- Attempting IV access
- Moving/upsetting/changing position of child (keep sat on parents lap)

Peri-operative:
- Position on parents lap sat up
- Resus drugs drawn up
- Difficult paediatric intubation equipment
- Trained anaesthetic assistant
- Choice of induction inhalational induction spont ventilating
- IV access once child unconscious
- Induction may take longer due to airway obstruction
- Once intubated - blood cultures, swabs, IV fluids, IV antibiotics, steroids if indicated, humidifed gases

Post-operative:
- Critical care environment
- Keep intubated 2-3 days
- IV antibiotics
- Leak test
- Fibreoptic nasendoscopy by ENT

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18
Q

Complications of paediatric tracheostomy?

A

Immediate:
- Loss of airway
- Bleeding
- PTX
- Oesophageal injury
- Damage to recurrent L N

Early:
- Accidental decanulation
- Obstruction 2ndary secretions
- Bleeding
- Infection

Late:
- Granuloma formation at the stoma
- Erosion into a vessel e.g. ext. carotid
- Suprastomal collapse
- Tracheal stenosis
- Tracheo-oesophageal fistula

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19
Q

Midface fracture repair - principles

A
  1. Intubation may be difficult due to anatomical distortion
  2. Shared airway
  3. Oral ETT may interfere with surgical access
  4. Facial nerve monitoring likely to be required
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20
Q

Midface fracture repair - “how to”

A

Pre-op:
- Surgical repair usually semi-elective, allows for fasting and resuscitation
- Discussion with surgeon about type of ETT req

Intra-op:
- Extensive blood loss - 2x wide bore IV access, x-match
- Single dose NMBD for facial n. monitoring
- Nasal ETT, submental, retromolar ETT
- Throat pack
- IV dex

Post-op:
- Intermaxillary fixation (wiring vs. elastic bands), wire cutters at bedside
- Significant oropharyngeal swelling therefore HDU/ICU admission

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21
Q

Important components of pre-op assessment for FESS?

A

In addition to my usual… I would focus on

Airway - bag mask ventilation may be difficult due to nasal obstruction

Co-morbidities
- asthma/bronchiectasis/LRTI common
Severity + stability
Intercurrent URTI and implications

Drug hx
- NSAIDS - asthma trigger ?
- MAOi - topical vasocontrictors
- Antiplatelets HOLD

Day case criteria - does it meet ?

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22
Q

Why is it important to reduce blood loss in ENT surgery ?

A
  1. Obscures surgical field - increasing length/difficulty
  2. Associated with PONV (intragastric blood = emetogenic)
  3. Risk of aspiration e.g. on extubation
  4. RARE = haemodynamic instability with significant loss
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23
Q

Methods to reduce blood loss in FESS

A

NON-pharmacological methods
1. Patient positioning
- Head up 10-20deg, dec venous congestion, dec. preload 2ndary venous pooling therefore dec. arterial BP in arteries of nose
- Low PEEP (<5cmH2O) - dec venous congestion due to improved drainage

Pharmacological
- Hypotensive anaesthesia - inc. MAC/clonidine/labetalol
- Cocaine (ester L.A with NRI properties). BEWARE may cause HTN/tachycardia/arrythmias/acute angle closure glaucoma
- Phenylephrine (Co-phenylcaine Lidocaine 5% with phenylephrine)
- Oxymetazoline (a-1 agonist like phenyl, good in children)
- Corticosteroids
- TXA (anti-fibrinolytic)

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24
Q

Airway options for FESS surgery?

A

Flexible LMA
- LMA cuff offers some protection from blood/secretions
- Does not require NMBD
- Spont ventilation dec. intrathoracic pressure as avoids IPPV

Disadvantages - may not be suitable in all patients e.g. obesity, GORD, difficult airway

South-facing RAE ETT
Advantages - complete airway protection intra-op
Disadvantages - as above, high risk of endobronchial intubation

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25
Methods to reduce retained throat pack?
It is a 'never event' Methods include 1. Inserted by surgeon and included in 'swab count' 2. Throat pack forehead stickers 3. Radiopaque thread 4. Tieing to ETT 5. Leave protruding from mouth 6. Integrate into WHO checklist 7. Not using throat pack at all
26
PERIOPERATIVE mx. of patient with OSA (ignore pre-op and post-op
Pre-op avoid benzo pre-meds due to resp depressant effects INDUCTION - Regional or local techniques prefrred over GA - all anaesthetic agents (with exception of ketamine) reduce central respiratory drive and pharyngeal muscle tone - Ensure adequate pre-oxygenation in sitting position (maximise FRC) - Consider using CPAP (water's circuit or HFNO) - ETT preferred over LMA (inc. airway security, GORD is higher risk in OSA patients with obesity) - Expect difficult BVM and or laryngoscopy, difficult airway trolley, oxford help, assistance - Multi-modal analgesia as opioid sparing - Consider desflurane due to faster emergence - TIVA models difficult in obese EMERGENCE - Fully reversed NMBDs - Sat up to maximise FRC - Fully awake - Commence CPAP in recovery, ideally patient's own machine, or HFNO HDU consider post op
27
Consequences of obesity hypoventilation syndrome (OHS)
RV remodelling - Hypoxaemia causes hypoxic pulmonary vasoconstriction - Leads to pulmonary HTN - RV remodelling - Inc. venous hydrostatic pressure --> peripheral oedema + hepatomegaly Polycythaemia - Due to hypoxaemia TREATMENT = weight loss/exercise/bariatric sx/CPAP
28
Anaesthetised airway risks pulmonary aspiration
If topical anaesthesia - NBM 2hrs If airway blocks - NBM 4hrs
29
Complications of Thyroid surgery
1. Neck haematoma 2. Hypocalcaemia - Damage to parathyroid glands - Perioral tingling, twitching, tetany - Trouseaus Chovstek - Risks laryngospasm, QT prolongation, arrythmias 3. Recurrent laryngeal nerve palsy - Ischaemia/traction/transection of nerve - Unilateral vs. bilateral palsy 4. Tracheomalacia - Tracheal collapse due to erosion of tracheal cartilages caused by long-standing goitre - Immediate re-intubation often required
30
Thyroid surgery - induction consideration
When no airway concerns, IV induction with paralysis and intubation using reinforced ETT D/w surgeon re: paralysing agent and NIM tube nerve monitoring If concern re: airway or tracheal compression then other techniques Inhalational induction Awake fibreoptic Tracheostomy under L.A Ventilation through rigid bronchoscope
31
Thyroid surgery - intraoperative considerations
Maintanence with volatile or TIVA Remifentanil - Hypotensive anaesthesia - Reduce laryngeal reflexes therefore no further muscle relaxant required 15 deg head up to decrease venous pressure Dexamethasone 8mg IV to reduce post op airway oedema Haemostasis - valsalva manouvre Analgesia
32
Neck haematoma evacuation mnemonic
SCOOP Skin Exposure - remove dressings Cut subcutaenous sutures Open skin - push fingers into wound Open muscle - open strap muscles to expose trachea Pack wound
33
Neck haematoma management
Recognise High flow O2 Nurse at 45 degrees Immediate senior surgeon + anaesthetist review Any signs of airway compromise - SCOOP if anterior neck Prepare for intubation, expect difficult airway
34
What is within the posterior fossa
Most inferior to cranial fossae Contains cerebellum, brainstem and lower cranial nerves Comprised of - Occipital bone postero-inferiorly - Temporal bone anteriorly and laterally - Sphenoid bone anteriorly and medially Roof is tentorium cerebelli Compact with poor compliance, small tumour = high ICP with risk of brainstem compression
35
What is an acoustic neuroma?
AKA vestibular schwannoma Benign tumour of myelin-forming Schwann cells of vestibular nerve (8th) Features: Unilateral hearing loss, tinnitus, imbalance, unsteadiness, vertigo (VIII) LARGE TUMOURS affect V and VII CN Proximity to VII necessitates EMG monitoring
36
Posterior fossa "how to" pre-op
Usual anaesthetic assessment + Evaluation of cranial nerve dysfunction Assessment for presence of raised ICP
37
Posterior fossa "how to" intra-op
Positioning - supine or park bench Resus drugs drawn up IV access secured on uppermost limb Monitoring including art line awake if high ICP and EMG monitoring + BIS + temp + IDC Airway = reinforced ETT Drugs + Ex drawn up Induction - smooth haemodynamically stable avoid CPP hypoperfusion and hypertension, high dose remi Single dose muscle relaxant Maintain with TIVA Extubation smooth extubation no coughing/straining and ICP spikes
38
Issues specific to posterior fossa surgery
Intraoperative brainstem handling may cause cardiovascular instability, hypertension and bradycardia Optimise physiology to maximise CPP Avoid hypoxia PaCO2 4.5-5.0 Temp control Plasma glucose 4-11mmol/L MAP >80 Obtund sympathetic response V. emetogenic so antiemetics
39
What are the classic features of spinal epidural abscess and what other features may be present?
Classic triad 1. Back pain 2. Fever 3. Abnormal neurology Other features 1. Nerve root pain 2. Motor weakness 3. Sensory deficit 4. Bowel/bladder dysfunction 4 Stages: 1. Back pain affected site 2. Nerve root pain radiating from affected area 3. Motor weakness, sensory deficit, bladder/bowel dysfunction 4. Paralysis
40
Causes of epidural abscess
90% Staph Aureus Remainder strep and gram -ve anaerobes
41
AAGBI BEST EPIDURAL PRACTICE
Monitored by staff aware of significance and action required in response to abnormal values Monitoring - HR and BP - RR - Sedation score - Temp - Pain score - Degree of motor and sensory block
42
What is required for venous air embolism to occur
1. Source of gas 2. Communication between this source and venous system 3. Pressure gradient enabling movement of gas 1ml/kg rapidly embolised can be fatal
43
Signs of venous A.E
Depends on volume of air, rate of entrainment, patient awake/anaesthetised Rapid entrainment - Classic cardiovascular embolic phenomenon: tachy, hypotension, hypoxaemia Neurological - confusion, focal signs, dec. GCS ECG abnormalities
44
VAE pathophysiology
AIr lock - Air in rv occupies it and prevents blood flow into pulmonary circulation Inflammation in pulmonary arterioles Small bubbles of air into RV and pulm. circ Mico emboli in pulmonary arterioles Paradoxical A.Emboli through patent FO may pass into arterial circ causing coronary or cerebral signs
45
Prevention of venous A.E
Avoiding sitting position - sitting craniotomy high risk Raised venous pressure at operative site - iv fluid loading, +ve PEEP Jugular venous compression has been reported Minimising time venous circulation open to atmosphere Minimising bubbles in IV lines
46
Post operative stridor management in paediatric inhaled foreign body case
Dexemethasone 150mcg/kg oral or IV Nebulised adrenaline 0.5ml/kg to a maximum of 5ml of 1:1000 Remember nbm 2-4hrs after lidocaine to cords
47
List 4 anaesthetic issues with fractured mandible
1. Possibility of other traumatic injuries 2. Difficult BMV 3. Potential for limited MO and difficult intubation 4. Shared airway 5. Potential for blood loss intraoral (aspiration risk), difficult airway, hypovolaemia
48
Anaesthetic choices in fractured mandible
Often patients can wait for suitable starvation GA/direct laryngoscopy if MO limited by pain North facing RAE Throat pack
49
Important aspects for emergence mandible ORIF
Confirm removal of throat pack at sign out Suction and inspect larynx for blood Awake extubation
50
Patient having neck dissection for cancer - anaesthetic considerations?
1. Co-morbidities with smoking and alcohol 2. Potential for difficult laryngoscopy 3. Shared airway 4. Bleeding from neck dissection
51
Name 5 comorbidities associated with smoking and tobacco use
COPD IHD Chronic Liver Disease Alcohol dependancy Malnutrition
52
Airway assessment in patient with head and neck cancer
Hx - voice change, dysphagia, breathlessness, positional symptoms, stridor Ex - Mallampati - Calder score - Mo - TM distance and TS distance Imaging = neck CT, FNE
53
Tell me about the Wilson Score
54
What challenges are posed by intra-oral abscess, name 3
1. Difficult airway 2. Shared airway surgery 3. Distortion of pharyngeal tissues causing partial airway obstruction 4. Abscess rupture during airway instrumentation may result in airway obstruction and soiling
55
What is trismus
Defined as a painful restriction in mouth opening due to spasm of muscles of mastication Mild 20-30mm Moderate 10-20mm Severe <10mm Causes: - Intra-articular - Fracture of condyle; TMJ dislocation; RA Extra-articular - Mandibular fracture not involving condyle - Acute infections e.g. dental abscess, quinsi - Tetanus - MH
56
What things should you do if worried about airway at induction
Doing induction in OT Having consultant anaesthetist and senior ODP available Have difficult airway equipment available Have ENT/maxsfacs surgeon in OT, ready to perform cricothyroidotomy
57
Describe the tympanic cavity
Air-filled space within petruous part of temporal bone Components: - Tympanic membrane (lateral wall of middle ear) - Three auditory ossicles malleus, incus, stapes - Oval window (medial wall of middle ear) - Eustachian tube Key muscles - stapedius, tensor tympani VII runs through middle ear and can be damaged
58
Why does middle ear surgery carry a risk of PONV
Younger patients Longer procedure times Direct stimulation of vestibular system due to - Drilling adjacent to middle ear - Suction-irrigation of middle ear
59
Middle ear surgery PREOP technique
Quiet well lit environment Take care of hearing aids
60
Middle ear surgery INTRAOP technique
Venous access - liaise with surgeons if superficial vein graft required and where taken from GA and ETT often required, long surgery, limited airway access Facial nerve monitoring with EMG - Single intubating dose of relaxant ok Nitrous is contra-indicated - More a problem post op where rapid absorption into blood causes sub atmospheric pressure which may affect surgical healing - TIVA with remifentanil for smooth extubation and low BP Minimal IV fluid to avoid catheterisation Avoid HYPERthermia - body covered with drapes, long procedure Multimodal antiemetics
61
3 ways of optimising surgical field in middle ear surgeryq1.
1. Induced hypotension - Aim for 80% of baseline MAP - Avoid v. low in patients at risk of stroke - Methods = increased volatile, increased propofol/remi, labetalol, MgSO4, clonidine 2. Reduced venous pressure - 10-20deg head up - Avoid ETT ties - Avoid extreme head rotation (occluded jugular) - Minimal or no PEEP 3. Controlled ventilation - PaCO2 4.5-5.0
62
What is a cholesteatoma
Abnormal growth of skin epithelium in middle ear Results in - Erosion of surrounding structures such as ossicle - Chronic infection - Erosion of facial nerve/inner ear Treatment by mastoidectomy
63
What are risk factors for PONV
1. Patient factors - Young - Female - Non-smokers - History of PONV or motion sickness 2. Anaesthetic factors - Volatiles - Nitrous - Intra-op opioids 3. Surgical factors - Gynae and breast - Middle ear - Optic surgery - Posterior fossa neurosurgery
64
APFEL scoring
0-4 Female Non-smoker History of PONV/motion sickness Use of opioids 0 = 10% 1 = 20% 2 = 40% 3 = 60% 4 = 80% risk Give 3 or 4 intraop antimetics if >2
65
Anaesthetic management of day case surgery
Consultant led service Prophylactic simple analgesia and antiemetics IV fluid use Maintainence of body temperature Anaesthetic techniques that favour early mobilisation e.g. prilocaine spinal Instructions for management of post regional/nerve block pain No driving/alcohol/machinery operating/legal documents for 24hrs
66
What is a pharyngeal poud
A pseudodiverticulum of the mucosa just above the cricopharyngeus muscle Main anaesthetic issue is regurgitation and aspiration at induction of anaesthesia, no prevented by application of cricoid pressure
67
Pathophysiology of pharyngeal pouch
Heniation of pharyngeal mucosa through weakest point (between bellies of thyropharyngeus and cricopharyngeus) Make up the inferior pharyngeal constrictor Food and debris become trapped causing - Halitosis - Regurgitation - Cough - Infection - Gurgling noise (borborygmus) May cause dysphagia and weight loss
68
How is pharyngeal pouch diagnosed
Barium swallow CT neck
69
3 complications of pharyngeal pouch surgery
1. Recurrent laryngeal nerve injury 2. Pouch perforation 3. Mediastinitis
70
Pharyngeal pouch surgery - PRE-OP
Patients are often elderly with associated co-morbidities History of pouch symptoms notably: - Positional regurgitation - Presence of dysphagia implying anatomical distortion
71
Pharyngeal pouch surgery - INTRA-OP
H2 antagonist pre-op AAGBI standard monitoring Trained assistant IV access Yankeur sucker on and underneath pillow INDUCTION: - Head up position, if patient reports usual regurgitatant symptoms - Avoid high pressure BVM (risks distention and rupture), consider HFNO - RSI with cricoid pressure - Pharyngeal suctioning - Soiling may require bronchoscopic washout

James' final FRCA SOE (19 decks)

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