Module 10

Question 1

Airway, Ear, Nose, and Throat Surgeries, LASER

Input Passage:

KEY POINTS → Laser

1. A basic principle of electricity is known as Ohm’s law (_______(1) = current x resistance).
2. To have the completed circuit necessary for current flow, a _______(2) must exist and a voltage source must drive the current through the impedance.
3. To receive a shock, one must contact the electrical circuit at two points, and there must be a voltage source that causes the current to flow through an individual.
4. In electrical terminology, grounding is applied to two separate concepts: the grounding of electrical power and the grounding of electrical equipment.
5. To provide an extra measure of safety from gross electrical shock (macroshock), the power supplied to most operating rooms (ORs) is _______(3).
6. The _______(4) is a device that continuously monitors the integrity of an isolated power system.
7. The _______(5) is a popular device used to prevent individuals from receiving an electrical shock in a grounded power system.
8. An electrically susceptible patient (i.e., one who has a direct, external connection to the heart) may be at risk from very small currents; this is called microshock.
9. Problems can arise if the electrosurgical return plate is improperly applied to the patient or if the cord connecting the return plate to the electrosurgical unit is damaged or broken.
10. Fires in the OR are just as much a danger today as they were 100 years ago when patients were anesthetized with flammable anesthetic agents.
11. The necessary components for a fire consist of the triad of heat or an _______(6), a fuel, and an oxidizer.
12. The two major ignition sources for OR fires are the _______(7) and the _______(8).
13. It is known that desiccated carbon dioxide absorbent can, in rare circumstances, react with _______(9) to produce a fire.
14. All OR personnel should be familiar with the location and operation of fire extinguishers.

Answer 1

Answers:

1. Voltage
2. closed loop
3. ungrounded
4. line isolation monitor
5. ground fault circuit interrupter
6. ignition source
7. electrosurgical unit
8. laser
9. sevoflurane

Question 2

Input Passage:

KEY POINTS → Otolaryngologic surgery

1. The restricted spaces in the airway require an understanding and cooperative relationship between surgeon and anesthesiologist, and the use of specially adapted equipment suitable to these cramped areas.
2. Despite only mild-to-moderate tonsillar enlargement on physical examination, children with obstructive sleep apnea have upper airway obstruction while awake and apnea during sleep. The clinician should not underestimate the severity of the problem based on tonsillar size alone.
3. Patients with obstructive sleep apnea have increased sensitivity to _______(1), and consequently the dose administered should be reduced by as much as _______(2).
4. Post-tonsillectomy hemorrhage may result in unappreciated large volumes of swallowed blood originating from the tonsillar fossa. These patients must be considered to have a _______(3).
5. The middle ear and sinuses are air-filled, nondistensible cavities. During procedures in which the eardrum is replaced or perforation is patched, _______(4) should be discontinued or, if this is not possible, limited to a maximum of 50% during the application of the tympanic membrane graft to avoid pressure-related displacement.
6. Systemic absorption of _______(7) agents during functional endoscopic sinus surgery may cause hypertension, bradycardia, tachycardia, and arrhythmias. Preoperative evaluation should include a thorough investigation of the patient’s cardiovascular status. Rapid response by the anesthesiologist to these effects is necessary in preventing complications.
7. Patients with a history of head and neck cancer may have surgical procedures and anesthesia which can affect specific organ systems, or radiation, which can have differential risk and health, in the _______(5).
8. _______(6) is commonly associated with other injuries and can influence airway management.

Answer 2

Answers:

1. opioids
2. 50%
3. full stomach
4. nitrous oxide
5. temporomandibular joint, rendering direct laryngoscopy difficult.
6. Facial trauma
7. vasoconstrictive

Question 3

Input Passage:

Tonsillectomy and Adenoidectomy

• Tonsillectomy is one of the more commonly performed pediatric surgical procedures.
• Chronic or recurrent acute _______(1), _______(2), tonsillar hyperplasia, and _______(3) (OSAS) are the major indications for surgery.
  
  • Patients with cardiac valvular disease are at risk for endocarditis from recurrent streptococcal bacteremia secondary to infected tonsils.
• Tonsillar hyperplasia may lead to chronic airway obstruction resulting in sleep apnea, carbon dioxide (CO2) retention, _______(4), failure to thrive, swallowing disorders, and speech abnormalities.
  
  • These risks are eliminated with removal of the tonsils.
• Obstruction of the oropharyngeal airway by hypertrophied tonsils →
  
  • apnea during sleep
  • referred to as _______(5)
• The goals of treatment are to relieve airway obstruction and increase the cross-sectional area of the pharynx.
• In children with longstanding hypoxemia and hypercarbia, increased airway resistance can lead to _______(6).

Answer 3

Answers:

1. tonsillitis
2. peritonsillar abscess
3. obstructive sleep apnea syndrome
4. cor pulmonale
5. obstructive sleep apnea syndrome
6. cor pulmonale

Question 4

Input Passage:

Possible qs: describe the pathway to develop cor pulmonale?
- Hypoxemia and hypercarbia > inc. Airway resistance > P-A _______(1) > pulm-arterial _______(2) >. R-S HF

Patients may have electrocardiographic evidence of
- right ventricular hypertrophy and radiographic evidence consistent with cardiomegaly.
- Each apneic episode causes progressively increased pulmonary artery pressure with significant systemic and pulmonary artery hypertension
- leading to ventricular dysfunction and cardiac dysrhythmias

The increased pulmonary vascular resistance and myocardial depression in response to hypoxia, hypercarbia, and acidosis are far greater than what is expected
- Cardiac enlargement is frequently reversible with surgical removal of the _______(3) and adenoids.
- _______(4) is the link between lung and heart dysfunction
- _______(5) medicine strengthens the force of heartbeat → inc. Ca++ in heart cells

Answer 4

Answers:

1. constriction
2. hypertension
3. tonsils
4. Pulmonary hypertension
5. Digitalis

Question 5

Preoperative Evaluation

• The physical examination should begin with observation of the patient.
• The presence of audible respirations, _______(1), nasal quality of the speech, and chest retractions should be noted.
  
  • _______(2) may be the result of chronic nasopharyngeal obstruction.
• An _______(3), a retrognathic mandible, and a high-arched palate may be present.
• The presence of _______(4) or rales on auscultation of the chest may be a lower respiratory component of upper airway infection.
• The presence of inspiratory stridor or prolonged expiration may indicate partial airway obstruction from hypertrophied tonsils or adenoids.
  parents should be questioned for current use of antibiotics, antihistamines, or other medicines.
• Many nonprescription cold medications and antihistamines contain aspirin, which may affect platelet function, and this potential anticoagulation
• Chest radiographs and electrocardiograms (ECGs) are not required unless specific abnormalities are elicited

Answer 5

Answers:
1. mouth breathing
2. Mouth breathing
3. elongated face
4. wheezing

Question 6

Anesthetic Management - tonsilectomy/adenoidectomy

• Premedication
  
  • may be used sparingly; sedative premedication should be avoided in children with obstructive sleep apnea, intermittent obstruction, or very large tonsils.
  • Use of an _______(1) will minimize secretions in the operative field.
  • She says not a fan of giving antísialagogue, but provider preference.
• Anesthesia is commonly induced with a volatile anesthetic agent, oxygen, and nitrous oxide (N2O) by mask.
  
  • Parental presence in the operating room (OR) during mask induction may be helpful in the anxious _______(2) child.
  • Tracheal intubation is best accomplished under deep inhalation anesthesia or aided by a short-acting nondepolarizing muscle relaxant.
  • _______(3) should be atraumatic.
• The addition of _______(6) µg/kg of dexmedetomidine infused during the procedure may help to attenuate _______(4) in toddlers at the conclusion of the anesthetic
  
  • To be given 15 minutes before the end of a case.
• Emergence from anesthesia
  
  • should be rapid, and the child should be alert before transfer to the recovery area.
  • The child should be _______(5) and able to clear blood or secretions from the oropharynx as efficiently as possible before removal of the endotracheal tube.
  • Maintenance of airway and pharyngeal reflexes is essential in the prevention of aspiration, laryngospasm, and airway obstruction.

Answer 6

Answers:
1. antísialagogue
2. unpremedicated
3. Intubation
4. emergence delirium
5. awake
6. 0.5 to 1

Question 7

ET tube or LMA?

• There is an emerging trend to use the flexible LMA for tonsillectomy, which protects the vocal cords from blood or secretions that may be present in the oropharynx.
  
  • This can increase the risk of _______(1).
  • Also mentions LMA may be too large, upsetting the surgical area and sterile field.
• The wide, rigid tube of the standard LMA model does not fit under the mouth gag and is easily compressed or dislodged during full mouth opening.
• Thus Havenstein prefers the use of oral ET tubes, possibly a _______(2) tube with surgical preference.

Answer 7

Answers:
1. laryngospasms
2. RAE

Question 8

Complications

• The incidence of post tonsillectomy mortality within the first 48 hours in both children and adults has been reported
  
  • increased in patients who are obese or have neurologic impairment or cardiopulmonary compromise.
• The incidence of emesis after tonsillectomy ranges from _______(1) to _______(2)
  
  • Decompressing the stomach with an orogastric tube may be helpful in preventing this response.
  • Give red rubber catheter to surgeons as they are in control of the surgical site, where a lot of incised tissue is near.
  • Treatment with _______(3), 0.10 to 0.15 mg/kg, either with or without _______(4), 0.5 mg/kg, has been shown to be very effective in reducing posttonsillectomy nausea and vomiting

Answer 8

Answers:
1. 30%
2. 65%
3. ondansetron
4. dexamethasone

Question 9

Complications

The most serious complication of tonsillectomy is postoperative _______(1)
- occurs at a frequency of 0.1% to _______(2)
- Approximately 75% of postoperative tonsillar hemorrhage occurs within _______(3) hours of surgery.
- Most of the remaining 25% occurs within the first _______(10) hours of surgery
- bleeding may be noted until the _______(4) postoperative day (thus the “six hours or six days” guideline).
- Average EBL is _______(5) or _______(6) of blood volume.

Unappreciated large volumes of blood originating from the tonsillar bed may be swallowed.
- Patients must be considered to have a _______(7).

Pain after adenoidectomy is usually minimal, but pain after tonsillectomy may be severe.
- An increase in postoperative pain medication requirements has been noted in patients having laser or _______(8) (tonsillectomy) compared sharp surgical dissection and ligation
- Intraoperative administration of _______(9) may decrease edema formation and subsequent patient discomfort

Answer 9

Answers:
1. hemorrhage
2. 8.1%
3. 6
4. sixth
5. 4ml/kg
6. 5%
7. full stomach
8. electrocautery
9. corticosteroids
10. 24

Question 10

Peritonsillar abscess, or ________(10)
- a condition that may require immediate surgical intervention to relieve potential or existing airway _______(1).
- This is a _______(2) and requires surgical intervention!
- An acutely infected tonsil may undergo abscess formation, producing a large mass in the lateral pharynx
- can interfere with swallowing and breathing.
- _______(3), _______(4), and _______(5) are frequent symptoms.
- _______(6) aka lockjaw
- Possible SATA: what are the 3 signs of quinsy tonsils?
- Treatment consists of surgical drainage of the abscess, either with or without tonsillectomy, and intravenous _______(7) therapy.
- usually in a fixed location in the lateral pharynx and does not interfere with ventilation of the patient by face mask after induction of general anesthesia.
- Visualization of the vocal cords should not be impaired because the pathologic process is _______(8) and well above the _______(9).
- Laryngoscopy must be carefully performed, avoiding manipulation of the larynx and surrounding structures.
- Intubation should be gentle
- The tonsillar area is tense and friable, and inadvertent rupture of the abscess can occur
- → spillage of purulent material into the trachea.
- A ________(11) position may be useful during laryngoscopy to decrease risk of purulent aspiration in the event of abscess rupture.

Answer 10

Answers:
1. obstruction
2. medical emergency
3. Fever
4. pain
5. trismus
6. Trismus
7. antibiotic
8. supraglottic
9. laryngeal inlet
10. quinsy tonsil
11. head-down

Question 11

Acute postoperative pulmonary edema
- an infrequent but potentially life-threatening complication encountered when airway obstruction is suddenly relieved.
- One proposed mechanism is that during inspiration before adenotonsillectomy → the negative intrapleural pressure that is generated causes an increase in venous return, enhancing _______(1).
- The anesthesiologist may attempt to prevent this situation during induction of anesthesia by applying moderate amounts of _______(2) to the airway,
- allowing time for circulatory adaptation to take place.
- signaled by the appearance of
- _______(3) fluid in the endotracheal tube of an intubated patient
- presence of decreased oxygen saturation, wheezing, dyspnea,
- _______(5) respiratory rate in the immediate postoperative period in a previously _______(4) patient.

Answer 11

Answers:
1. pulmonary blood volume
2. continuous positive pressure
3. frothy pink
4. extubated
5. increased

Question 12

Acute postoperative pulmonary edema

Patients should be observed for early hemorrhage for a minimum of _______(1) to _______(2) hours
- Recap what is the frequency - percentage of blood loss that can occur during the first 6 hours?
- _______(3)

• be free from significant nausea, vomiting, and pain prior to discharge.
• The ability to take fluid by mouth is not a requirement for discharge home.
  
  • However, intravenous hydration must be adequate to prevent dehydration.
  • Procedure is painful for child post-op may not want to drink → give _______(4) during procedure.

Palatine Tonsils (no idea where in the book this is from just pasted it on.)
- Blood flow to tonsilar arises via the _______(5) and its branches:
- the _______(6) artery, _______(7) artery, _______(8) artery
- _______(9) branch of the maxillary artery
- Sensory innervation to the palatine tonsils is supplied by the _______(10) and _______(11) nerves.

Answer 12

Answers:
1. 4
2. 6
3. 75%
4. extra fluid
5. external carotid
6. ascending pharyngeal
7. facial
8. dorsal lingual
9. palatine
10. glossopharyngeal
11. lesser palatine

Question 13

Post-Tonsillectomy Bleeding
Got this from the ppts “StiCK wiTH BaRash”
- Place kid in _______(1) position, eg, lateral position. RSI always! Always Cuffed. Expect bleeding after _______(2) hours post-op.
- Due to scab in throat dislodging after cough or vomiting results in post-op bleeding.
- This commonly happens!

48-1 Tonsillectomy and Adenoidectomy Inpatient Guidelines: Recommendation of the American Academy of Otolaryngology—Head and Neck Surgery

Admit patients to the hospital after adenotonsillectomy if they meet any of the following criteria:
- Age ≤ _______(3) yrs
- Severe OSA with an apnea–hypopnea index of _______(4) or more obstructive events/hr, oxygen saturation nadir <_______(5)%, or both
- Abnormal coagulation values with or without an identified bleeding disorder in the patient or family
- Systemic disorders that put the patient at increased perioperative cardiopulmonary, metabolic, or general medical risk
- Child with craniofacial or other airway abnormalities including, but not limited to, syndromic disorders such as Treacher Collins syndrome, Crouzon syndrome, Goldenhar syndrome, Pierre Robin anomaly, CHARGE syndrome, achondroplasia, and, most prominently, Down syndrome, as well as isolated abnormalities such as choanal atresia and laryngotracheal stenosis
- When extended travel time, weather conditions, and home social conditions are not consistent with close observation, cooperation, and ability to return to the hospital quickly at the discretion of the attending physician

CHARGE, coloboma of the eye, heart defects, atresia of the choanae, retardation of growth and/or development, genital and/or urinary abnormalities, and ear abnormalities.

Possible SATA qs.. Or Which of these kids require hospitalization?

Answer 13

Answers:
1. tonsil
2. 72
3. 3
4. 10
5. 80%

Question 14

Ear Surgery

Myringotomy and Tube Insertion
- Indication: _______(6) in children can lead to hearing loss.
- When left untreated may cause “_______(1)” which can lead to hearing loss in the patient.
- Drainage of accumulated fluid in the middle ear is an effective treatment for this condition.
- _______(7), which creates an opening in the tympanic membrane for fluid drainage, may be performed alone
- Myringotomy with _______(2) is a relatively short procedure, and anesthesia may be effectively accomplished with a potent inhalation agent, oxygen, and N2O administered by face mask.
- Sevo 8% and 70% nitrous, supercharge circuit. Roll with them until 2 good cries. Then put pulse Ox and EKG leads once asleep. Turn the agent down and mask.
- Premedication is not recommended because most sedative drugs used for premedication will far outlast the duration of the surgical _______(3).
- This is what barash says however, havenstein says _______(4) does wonders!
- You do not want to scare the kid. Also give motrin and tylenol. Says 1mg/kg of _______(5) is fantastic. Give it time to work.
- Patients with chronic otitis frequently have accompanying recurrent URI.
- It is often the eradication of middle ear fluid that resolves the concomitant URI
- Insertion of myringotomy tubes may be undertaken in most children with a concomitant URI provided that this can be completed with face mask anesthesia and endotracheal intubation is avoided.

Answer 14

Answers:
1. Glue Ear
2. tube insertion
3. procedure
4. oral midazolam
5. ketorolac
6. Chronic serous otitis
7. Myringotomy

Question 15

Middle Ear and Mastoid
- _______(6) are two of the most common procedures performed on the middle ear and accessory structures.
- To gain access to the surgical site, the head is positioned on a headrest, which may be lower than the operative table, and extreme degrees of lateral rotation may be required.
- Extreme tension on the heads of the sternocleidomastoid muscles must be avoided.
- The head is gonna be away from you. Expect to go _______(1) → long circuit.
- prone to _______(2) subluxation.
- _______(3) nerve identification!
- Ear surgery often involves surgical identification and preservation of the _______(4) nerve,
- requires isolation of the nerve by the surgeon and verification of its function by means of electrical stimulation
- accomplished by brainstem auditory evoked potential and electrocochleogram monitoring
- requires that _______(5) be avoided

Answer 15

Answers:
1. 180
2. C1 to C2
3. Facial
4. facial
5. complete muscle relaxation
6. Tympanoplasty and mastoidectomy

Question 16

Middle Ear and Mastoid Procedures

Hemostats!
- Bleeding must be kept to a minimum during surgery of the small structures of the middle ear.
- Minimizing excessive _______(1) in blood pressure and normotension can be helpful in improving the surgical field.
- Relative hypotension can also be effective.

Avoid _______(2)!
- Contributes to N&V, unseats graphs, and add pressure
- barash explanation → The middle ear and sinuses are air-filled, nondistensible cavities.
- An increase in the volume of gas in these structures results in an increase in pressure.
- N2O diffuses along a concentration gradient into the air-filled middle ear spaces more rapidly than nitrogen moves out.
- Passive venting occurs at 20 to 30 cm H2O pressure, and it has been shown that the use of N2O results in pressures that exceed the ability of the eustachian tube to vent the middle ear within 5 minutes, leading to pressure buildup.

Answer 16

Answers:
1. increases
2. nitrous oxide

Question 17

Airway Surgery

Stridor

Causes of Stridor:

• Possible SATA which of these are supra? Sub? Located in the larynx?
  
  • Chatgpt

Supraglottic Airway: 1
- “Lovable Vocalists Seldom Have Critics”
- Lovable for _______(1)
- Vocalists for _______(2) paralysis
- Seldom for _______(3) stenosis
- Have for _______(4)
- Critics for _______(5)

Larynx: 2
- Larynx Infections Frequently Cause Catastrophe
- Larynx for _______(1)
- Infections for Infection (A)
- Frequently for _______(2)
- Cause for _______(3)
- Catastrophe for ____(4)

Subglottic Airway:
- Teachers Value Flawless Intonation
- Teachers for _______(5)
- Value for _______(6)
- Flawless for _______(7)
- Intonation for Infection (B)

• Noisy breathing due to obstructed airflow is known as stridor.
• Inspiratory stridor results from _______(8) obstruction
• expiratory stridor results from _______(9) obstruction
• biphasic stridor is present with _______(10) lesions.

Answer 17

Answers: 1
1. Laryngomalacia
2. Vocal cord
3. Subglottic
4. Hemangiomas
5. Cysts

Answers:
1. Laryngocele
2. Foreign body
A. tonsillitis, peritonsillar abscess
3. Choanal atresia
4. Cysts and cranioabnormalities
5. Tracheomalacia
6. Vascular ring
7. Foreign body
B. croup, epiglottitis
8. upper airway
9. lower airway
10. mid tracheal

Question 18

Laryngomalacia
- the most common cause of _______(1) in infants.
- It is most often due to a long epiglottis that prolapses posteriorly and prominent arytenoid cartilages with redundant aryepiglottic folds
- obstructs the glottic opening during _______(2).
INHERITED
- Many times, laryngomalacia will _______(3) as patients grow older
- though patients with severe obstructive symptoms may need surgical intervention.

Answer 18

Answers:
1. stridor
2. inspiration
3. improve

Question 19

Foreign Body Aspiration
- Vast majority of airway foreign bodies (AFB) occur in children under the age of _______(1) years, with peak incidence occurring between _______(2) and _______(3) years of age.
- In younger children, the most common item aspirated is the _______(4) followed by popcorn, jelly beans and hot dogs.
- Sounds like natural selection to me.
- In older children, the most common item aspirated is non food items, such as a coin.
- The most common site of AFB is the _______(5) stem bronchus, _______(10) side more often
- For the same reason you end up with more R. _______(6) intubations
- Classic triad of AFB includes: _______(7), _______(8), and diminished breath sounds.
- _______(9) which occurs while eating is a good indication of aspiration!

Answer 19

Answers:
1. 3
2. 1
3. 2
4. peanut
5. main
6. mainstem
7. wheezing
8. cough
9. Coughing, choking, and cyanosis
10. right

Question 20

Common Radiographic Findings
- Radiopaque object
- Atelectasis
- Emphysema (obstructive with a mediastinal shift)
- Consolidation
- +/- normal x-ray depending upon time of injury

“A question on any part of this is Fair Game- All of this Stuff makes sense” God i hate that phrase
- Possible qs
- you hear a patient wheezing on expiration you know that the foreign body is most likely at?
- Anywhere from the trachea to alveoli
- t/f chocking is an important seen often seen with fba
- False, not always witnessed - especially with younger children

AFB Extraction: How?
- The Answer is a _______(1)
- Put the patient to sleep, and go down
- Hope you can Pull whatever is there out

Anesthetic Issues
- +/- premedication?
- EMLA crème before starting IV
- Full stomach _______(2)
- If not at risk for _______(3), then consider Sevoflurane induction
- Ie if whatever they aspirated is way far down there, not obstructing airway

Controversy: _______(6) ventilation may be preferred but gentle _______(4) ventilation may be necessary if oxygenation/ventilation is insufficient versus _______(5) ventilation with muscle relaxants to avoid coughing and bucking during bronchoscopy.
- If spontaneous ventilation induction, consider 1 - 2% lidocaine spray for larynx and vocal cords to facilitate fiberoptic bronchoscopy.

Answer 20

Answers:

1. Bronch
2. RSI
3. aspiration
4. assisted
5. controlled
6. Spontaneous

Question 21

Complications of AFB Removal
- Rigid bronchoscopy: _______(6) to lips, teeth, base of tongue, epiglottis and larynx
- _______(1) rare but could happen
- (pneumothorax, hemothorax, pneumomediastinum and emphysema may be possible)
- Inadequate ventilation = _______(2) (arrhythmias) & _______(3)
- Hypoxia = _______(4) = if untreated, then _______(5)
- Bronchospasm and laryngospasm

Answer 21

Answers:
1. Lower airway damage
2. hypercarbia
3. hypoxia
4. bradycardia
5. cardiac arrest
6. trauma

Question 22

Nasal Surgery

• _______(5) most common procedure for chronic sinusitis.
• Balloon sinuplasty
• Rhinoplasty
• Septoplasty
• Simple vs complex procedures
  
  • Always think Airway
  • Expect bleeding- into _______(3)
  • Bleeding into Airway= Spasms, problems, vomit

Issues: optimal visualization of surgical field, bleeding kept to minimum
Practice: vasoconstrictors, _______(4) of head & modest hypotension (issues systemic absorption of vasoconstrictors
- You’ve given vasoconstrictor in the nasal mucosa
- so your body is going to absorb it systemically
- So you may have more high blood pressure than you expected
- TIVA versus volatile agent (PONV, emergence issues)

Answer 22

Answers:

3. airway
4. elevation
5. Functional Endoscopic Sinus Surgery (FESS)

Question 23

Death related to nasal surgery: case report with review of therapy-related deaths.

…a rare death occurring as a complication of septoplasty, nasal polypectomy, and intranasal endoscopic ethmoidectomy, which are common surgical procedures performed by EENT surgeons.

An otherwise healthy 58-year-old woman underwent the elective surgical procedures for a deviated nasal septum, multiple nasal polyps, and chronic ethmoid sinusitis. Following surgery, the patient never awoke from general anesthesia, and further evaluation before death revealed a basilar subarachnoid hemorrhage. Autopsy disclosed basilar subarachnoid hemorrhage, a traumatic defect of the right cribiform plate, and associated anterior cerebral artery injury with frontal lobe damage. No vascular anomalies were present. The cause of death was attributed to complications related to nasal surgery…

Maxillofacial Trauma
- Lower third: _______(1), _______(2) area, _______(3), body of angle _______(4), coronoid _______(5)
- Mnemonic: Lately, My Smile Really AttraCts Crowds
- Middle third: _______(6), _______(7), Nasal bones and Orbits
- Mnemonic: “Merlin the Magixian Zaps Nose Off”
- Upper third: Frontal _______(8) bone
- Mnemonic: “Upset Forehead”

Answer 23

Answers:
1. Mandible
2. symphseal
3. ramus
4. condyle
5. process
6. Zygoma
7. Maxilla
8. Facial

Question 24

LeFort I
- An _______(1) or _______(2) intubation can be accomplished in almost all cases.
- Often used to correct _______(3) deformities
- Worries:
- _______(4) in Airway
- Jaw that is Wired Shut
- Make them EARN extubation

LeFort II
- _______(5), involving the thick upper part of the nasal bone & the thinner part forming the upper margin of the anterior nasal aperture
- _______(6) is contraindicated.
- Can thread ETT right into brain

Answer 24

Answers:
1. oral
2. nasal
3. dento-facial
4. Blood
5. Pyramidal
6. Nasal intubation

I for Intubate!
II Ns - No Nasal

Question 25

LeFort III
- Runs parallel to the _______(1), separating the midfacial skeleton from the base of the skull
- Basal skull→ _______(2), _______(3) and exposure of _______(4) sinuses, or “air cells,” to air to infection.
- Loss of supporting facial structure = difficult intubation; early _______(5)

LASER
- How is laser light different from ordinary light?
- What does LASER stand for?
- _______(6)
- What preventive measures are taken for laser surgery?
- What components are needed for an airway fire?
- How is an airway fire managed?

Answer 25

Answers:
1. base of the skull
2. CSF
3. rhinorrhea
4. ethmoidal
5. tracheostomy
6. Light Amplification Stimulated Emission Radiation

Three for threacheostomy!

Question 26

Argon
Uses? 1.
Orange (Apex: A for Amber)

KTP or YAG
SAA
Color?

Nd: YAG
Uses? 3
Green (Apex: G for yaG)

CO2
Oropharynx, vocal cords, Plastic surgery, Urology, GYN
Color? 4 (Apex C: for Co2)
Just need something to deflect the beam

Answer 26

1. Eye; Dermatologic
2. Orange/Red
3. Tissue debulking trachea, upper bronchus
4. Clear

Question 27

Safety Protocol for Surgical Lasers

• Post warning signs outside any OR.
• Patients’ eyes should be protected with appropriate colored glasses and/or wet gauze.
• Matte finish (black) surgical instruments reduce beam reflection & dispersion
  
  • Prevent anything from being deflected at _______(1).
• Use the lowest concentration of oxygen as possible.
• Avoid _______(2) as it supports combustion.
• Lasers should be placed in STANDBY mode when not in use.

Safety Protocol for Surgical Lasers

• Use an endotracheal tube specifically prepared for use with lasers.
• Inflate cuff of laser tube with _______(3) so that a cuff perforation is readily apparent.
• All adjacent tissues should be shielded by wet gauze to prevent damage by reflected beams.
• _______(4) should be suctioned and evacuated from the surgical field.

Answer 27

Answers:
1. someone else’s eye
2. N2O
3. dyed saline
4. Plume

Question 28

Head and Neck Cancer Surgery

• Laryngectomy, glossectomy, pharyngectomy, parotidectomy, hemimandibulectomy and radical neck dissection
• Endoscopic exam after induction, tracheostomy and microvascular muscle flap
• Preoperative: Heavy tobacco & alcohol usage, co-existing diseases
• Abnormal airway issues, preoperative radiation, direct laryngoscopy, fiberoptic, or elective tracheostomy

Monitoring
- Blood loss, co-existing diseases, a-line, CVP (consider the location of surgery—femoral line)- you’re not going to place a CVP if you are doing head/neck surgery
- If a “forearm flap,” consider IV lines, etc.
- Consider what vasoconstrictors you’ll use- More Vasoconstricters=_______(2) perfusion to the _______(1).
- Forced air warming
- Intraoperative nerve monitoring (anterior neck operations) preserve SLN, RLN & vagus nerves
- Medtronic Xomed NiM® Endotracheal tube

Answer 28

Answers:
1. Flap
2. Less

Question 29

Nerve Injuries

• The vagus nerve (cranial nerve X) originates in the _______(1) and then ramifies in the _______(2) and _______(3) ganglia in the neck
  
  • Its first major branch is the _______(4) of the vagus.
• The _______(5) laryngeal nerve divides into the external and internal laryngeal nerves.
  
  • The _______(6) branch supplies sensory innervation of the laryngeal mucosa above the vocal cords
  • The _______(7) branch innervates the inferior pharyngeal constrictor muscles and the cricothyroid muscle of the larynx.
    
    • _______(11) muscle contraction increases the voice pitch by lengthening, tensing, and _______(8) the vocal folds.
  • The superior laryngeal nerve is at risk of damage during operations of the _______(9) neck, especially _______(10) surgery, and injury to this nerve may result in hoarseness and loss of vocal volume.

Answer 29

Answers:
1. medulla oblongata
2. superior
3. inferior vagal
4. pharyngeal plexus
5. superior
6. internal
7. external
8. adducting
9. anterior
10. thyroid
11. Cricothyroid

Question 30

• The next branch of the vagus is the _______(1) laryngeal nerve, which innervates all of the muscles of the larynx except the _______(2)
  
  • responsible for _______(3) and _______(4) opening.
• The recurrent laryngeal nerve runs immediately behind the _______(5) gland and thus is the nerve of greatest risk for injury during _______(6) surgery.
  
  • _______(7) recurrent laryngeal nerve damage may result in vocal changes or hoarseness
  • _______(8) nerve damage may result in aphonia and respiratory distress
• Inferior to this nerve, the vagus nerve provides autonomic motor and sensory nerve fibers to the _______(9) and _______(10) viscera.

Answer 30

Answers:
1. recurrent
2. cricothyroid
3. phonation
4. glottic
5. thyroid
6. thyroid
7. Unilateral
8. bilateral
9. thoracic
10. abdominal

Question 31

“NIM Tube”

• FIGURE 37-3
• A: The Medtronic Xomed NIM® electromyographic (EMG) nerve integrity monitoring endotracheal tube.
  
  • _______(1) (or no relaxant at all) should be used for intubation
  • the tube should be secured in the _______(2).
  • If lubricant is used, it must not contain local anesthetics.
• B: A slightly _______(3) tube size should be used to facilitate mucosal contact with the electrodes
  
  • The blue band of the NIM® tube must be positioned at the level of the _______(4).
• C: Nerve integrity is continuously monitored via _______(5) (Medtronic Xomed NIM-Response® 3.0 Nerve Integrity Monitor).
  
  • _______(6) muscle relaxants are contraindicated because they preclude EMG monitoring. (Redrawn and reproduced, with permission, from Medtronic Xomed.)

Answer 31

Answers:
1. Succinylcholine
2. midline
3. larger
4. vocal cords
5. EMG activity
6. Nondepolarizing

Question 32

Eye Procedures

Maintenance of Anesthesia
- Surgeon may request no NMBs during many EENT procedures to include neck dissections, parotidectomy, etc.
- Moderate controlled hypotension may be helpful but be mindful of cerebral perfusion (i.e., a-line zeroed at _______(1)).
- Microvascular free flap → issues with vasoconstrictors and vasodilators; avoid excessive diuresis.
- Transfusion decisions (recurrence of cancer rates increase).
- Manipulation of carotid sinus and stellate ganglion.

Facial Nerve Monitoring
- Nerve stimulated → Muscle twitch
- _______(2) muscle
- _______(3) muscle

Answer 32

Answers:
1. external auditory meatus
2. Orbicularis oculi
3. Orbicularis oris

Question 33

Ch 49: Ophthalmologic Surgery

KEY POINTS → Ophthalmologic Surgery

1. Cataract surgery is one of the most frequently performed surgical procedures worldwide but represents just one aspect of the various ophthalmic subspecialties, which include cornea, retina, glaucoma, uveitis, strabismus, oculoplastic, and oncology surgeries.
2. Eye surgery patients are often at the _______(1) of age, ranging from premature babies with retinopathy of prematurity to nonagenarians with multiple coexisting diseases in which age-related anesthetic considerations are key.
3. With intraocular procedures, globe akinesia, patient movement, and control of intraocular pressure (IOP) are important variables; however, with _______(2) surgery, the significance of IOP fades, whereas elicitation of the _______(3) becomes a concern.
4. Inhalation anesthetics cause dose-related _______(4) in IOP. The exact mechanisms are unknown, but postulated causes include depression of a control center in the diencephalon, reduction of aqueous humor production, enhancement of aqueous outflow, or relaxation of the _______(5) muscles.

Answer 33

Answers:
1. extremes
2. extraocular
3. oculocardiac reflex
4. reductions
5. extraocular

Question 34

KEY POINTS → Ophthalmologic Surgery

5. The _______(1) reflex is triggered by pressure on the globe and by traction on the extraocular muscles as well as on the conjunctiva or on the orbital structures. This reflex, whose afferent limb is _______(2) and efferent limb is _______(3), may also be elicited by performing a regional eye block, by ocular trauma, and by direct pressure on tissue remaining in the orbital apex after enucleation.
6. Ophthalmic drugs may significantly alter the patient’s reaction to anesthesia. Similarly, anesthetic drugs and maneuvers may dramatically influence intraocular dynamics.
7. Several anesthetic options are available for many types of ocular procedures, including general anesthesia, retrobulbar (intraconal) block, peribulbar (extraconal) anesthesia, sub-Tenon block, topical analgesia, and intracameral injection.
8. The complications of ophthalmic anesthesia can be both vision- and life-threatening.

Answer 34

Answers:
1. oculocardiac
2. trigeminal
3. vagal

Question 35

Optic Nerve & Macula

• Optic nerve (the bright light)
• Macula: dark mass near the center of the retina, containing _______(1)-sensitive rods and the central point of sharpest vision
• Rods & Cones (see next slide)

Rods & Cones

• Retina: thin layer that lines the back of the eye
  
  • Where the _______(2) are located.
  • If you think of the eye as a camera, the retina would be the film. The retina also contains the nerves that tell the brain what the photoreceptors are “seeing.”
• There are two types of photoreceptors involved in sight: _______(3) and _______(4).
  
  • Rods work at _______(5) levels of light. Think Radiates
    
    • We use these for night vision because only a few bits of light (photons) can activate a rod. Rods don’t help with color vision, which is why at night, we see everything in a gray scale. The human eye has over 100 million rod cells.
  • Cones require a lot more light and they are used to see _______(6).
    
    • We have three types of cones: _______(7), _______(8), and _______(9). The human eye only has about 6 million cones. Many of these are packed into the fovea, a small pit in the back of the eye that helps with the sharpness or detail of images.

Answer 35

Answers:
1. color
2. photoreceptors
3. rods
4. cones
5. very low
6. Color
7. blue
8. green
9. red

Question 36

Requirements of Ophthalmic Surgery

• _______(1)
  
  • loss or impairment of voluntary muscle movement.
• _______(2)
• Minimal bleeding
• Avoidance or obtundation of _______(3)
• Control of _______(4)
• Awareness of drug interactions
• Smooth emergence (avoid _______(5), _______(6), or _______(7))

Answer 36

Answers:
1. Akinesia
2. Analgesia
3. oculocardiac reflex
4. intraocular pressure
5. coughing
6. nausea
7. vomiting

Question 37

Table 31-3: Physiologic Influences on Intraocular Pressure

PHYSIOLOGIC VARIABLE | EFFECT ON INTRAOCULAR PRESSURE
— | —
Central Venous Pressure |
Increase | Marked increase
Decrease | Marked decrease

Arterial Blood Pressure |
Increase | Mild increase
Decrease | Mild decrease

PaCO2 |
Increased through hypoventilation | Moderate increase
Decreased through hyperventilation | Moderate decrease

PaO2 |
Increase | No effect
Decrease | Mild increase

________(1) | Marked increase
________(2) | Marked increase
Deep Inspiration | Mild decrease

Answer 37

Answers:
1. Coughing/Bucking
2. Vomiting

Question 38

Alterations in Choroidal Blood Volume

• Arterial blood pressure → autoregulation but 20% have abnormal regulation
• _______(1) pressure → greater role than arterial in IOP

Changes in acid-base homeostasis → respiratory or metabolic acidosis/alkalosis; hypoxia or hyperoxia
- Extraocular factors → contraction of orbicularis oculi muscle or contraction of other extraocular muscle will increase IOP (i.e., a “blink”= _______(2) mm Hg or a forceful lid closure = _______(3) mm Hg)

Answer 38

Answers:
1. Venous
2. 10
3. 50

Question 39

Clinical Conditions Increasing IOP via increases in Venous Pressure

• _______(7)Co2?
• _______(8)O2?
• Airway _______(9)
• Coughing/straining increases IOP _______(1) mm Hg
• _______(10) s/s?
• Over_______(11)
• Retrobulbar _______(12)
• Endotracheal intubation

Regional Anesthesia: Ophthalmic Surgery

• A successful block leads to _______(13), anesthesia and an abolished _______(14) reflex
• _______(2): bradycardia, junctional rhythm, or asystole can occur secondary to traction on the eye and ocular muscles)
  
  • TX → _______(3), Stop eye manipulation
• Factors that contribute to OCR- Preoperative anxiety, Light GETA, Hypoxia, Hypercarbia, Increase Vagal tone due to age or drugs
• Other Complications include the following: Retrobulbar Hemorrhage, Central Retinal Artery Occlusion, Puncture of the Posterior Globe, Penetration of the Optic Nerve, Inadvertent Brain Stem Anesthesia, Allergic reactions
• Two basic approaches: Retrobulbar block and Peribulbar block
• Oculocephalic reflex – movement of the eye for maintaining _______(4) gaze in response to rotation of the neck to a particular direction
• Oculocardiac reflex – 1st described in 1908. Traction of ocular muscles or pressure on globe cause _______(5), AV block, PVC’s or _______(6)

Answer 39

Answers:
1. 40
2. OCULO-CARDIAC REFLEX
3. Atropine
4. forward
5. bradycardia
6. asystole
7. Hypercarbia
8. Hypoxia
9. obstruction
10. Vomiting
11. hydration
12. hemorrhage
13. akinesia
14. oculocephalic

Question 40

Open Globe

• Limit increases in IOP (coughing, sneezing, etc.)
  
  • Hysterical child with open globe, no IV & full stomach → use a supercharge gas circuit inhalation induction — _______(1) sevo and _______(2) N2O
• Trauma or injuries associated with open globe
• Regional anesthesia relatively contraindicated
• General anesthesia: aspiration risk and increasing IOP with laryngoscopy (SCh INCREASES IOP _______(3) mmHg for _______(4) min)
• OCR
• PONV
• Extubation

Answer 40

Answers:
1. 8%
2. 50%
3. 8
4. 5-7

Question 41

Strategies to prevent increases in intraocular pressure

• Avoid direct pressure on the globe
  
  • Patch eye with _______(1) shield
  • no _______(2) or _______(3) injections
  • Careful with _______(4) techniques
• Avoid increases in CVP
  
  • Prevent coughing during induction & intubation
  • Recap: How much does IOP increase during coughing/straining? _______(5)
• Deep level of anesthesia before intubation
  
  • avoid _______(6) position
  • Extubate under deep anesthesia (sxn with OGT secondary to full stomach issues)
• Avoid pharmacological agents that increase IOP

Answer 41

Answers:
1. Fox
2. retrobulbar
3. peribulbar
4. face mask
5. 40mmHg
6. head down

Question 42

What are the anesthetic issues relative to retinal detachment procedures?

• Sulfurhexafluoride (SF6) is used during _______(1) repairs to form a bubble in the posterior chamber of the eye that flattens the retina and promotes correct healing.
• Nitrous oxide issues _______(5)x more soluble than Nitrogen & _______(6)x more soluble than SF6).
  
  • _______(2) bubble volume → Increases IOP, Decreases retinal blood flow, and compromising the retinal repair.
• SF6 remains in the posterior chamber for _______(3) or more days.
• Nitrous oxide should be avoided for at least _______(4) days.

Answer 42

Answers:
1. retinal detachment
2. Increases
3. 5
4. 10
5. 35
6. 117

Question 43

List three differences between retrobulbar and peribulbar blocks.

1. Needle Placement
   a. _______(6): needle punctures the bulbar fascia and enters orbital muscle cone.
   b. _______(7): needle is directed parallel and lateral to the bulbar fascia rather than passing through it.
2. LA volumes: Retrobulbar (_______(1) ml) whereas Peribulbar requires higher volumes (_______(2) ml) (combination of Lidocaine & Bupivacaine)
3. Effectiveness of Retrobulbar evaluated in _______(3) minutes; Peribulbar may take _______(4) to _______(5) minutes

Answer 43

Answers:
1. 2 to 4
2. 4 to 12
3. 2
4. 10
5. 20
6. Retrobulbar
7. Peribulbar

Question 44

What are the primary advantages and limitation to retrobulbar and peribulbar blocks? (a)

What facial nerve should be blocked alongside the retrobulbar block? Or which of the following nerves is not affected by retrobulbar block? (b)

Minor Complications of Ophthalmic Anesthesia
- Corneal abrasion – may NOT be minor
- Bruising
- Subconjunctival hemorrhage
- Chemosis
swelling (edema) of the conjunctiva, which is the clear tissue covering the white part of the eye and the inside of the eyelids.
- Transient diplopia

Differential Diagnosis of Altered Physiologic Status After Regional Anesthesia Eye Surgery (Find and study this table)

Answer 44

a.Retrobulbar Block:
Advantages:
1. Provides rapid, complete akinesia of the eye and eyelid.
2. Produces intense anesthesia suitable for most types of intraocular surgery.
3. Low volume of anesthetic agent is typically needed for the block.

Limitations:
1. Higher risk of complications such as globe perforation, retrobulbar hemorrhage, and optic nerve damage.
2. Risk of brainstem anesthesia if the anesthetic is inadvertently injected into the subarachnoid space.

Peribulbar Block:
Advantages:
1. Lower risk of serious complications compared to retrobulbar block due to the injection being further away from the globe and optic nerve.
2. Provides effective akinesia and anesthesia with a higher volume of anesthetic agent.

Limitations:
1. Slower onset of anesthesia and akinesia as compared to the retrobulbar block.
2. May require additional injections to achieve complete akinesia of the eye and eyelid.

b.CN VII

Question 45

Complications of Needle based Ophthalmic Anesthesia

• Stimulation of OCR
• Superficial hemorrhage: _______(8) hematoma
• Retrobulbar hemorrhage ± retinal perfusion compromise → _______(1)
• Globe penetration ± intraocular injection: retinal detachment, _______(2)
• Trauma to optic nerve or orbital cranial nerves: _______(3)
• Optic nerve sheath injection: orbital epidural anesthesia

Complications of Needle based Ophthalmic Anesthesia

• Extraocular muscle injury, leading to postoperative _______(4), _______(5) (double vision)
• Intra-_______(6) injection producing immediate convulsions
• Central retinal artery occlusion
• Inadvertent brainstem anesthesia → contralateral amaurosis, mydriasis, muscle paresis, neurocardiopulmonary compromise → _______(7)

Answer 45

Answers:
1. loss of vision
2. loss of vision
3. loss of vision
4. strabismus
5. diplopia
6. arterial
7. DEATH
8. circumorbital

Question 46

Symptoms of Brainstem Anesthesia

• Contralateral _______(1) (partial or total blindness without visible change in the eye typically due to disease of the optic nerve, spinal cord, or brain)
• _______(2) speech
• _______motor?(3)
• Altered _______(4)
• _______tension(5)
• Cardiovascular _______(6)
• ______breathing?_(7)

Answer 46

Answers:
1. amaurosis
2. Slurred
3. Hemiparesis
4. consciousness
5. Hypertension
6. collapse
7. Apnea

Question 47

Cranial nerves involved in the function of the eye:

• Optic (II) Cranial Nerve:
  
  • Function: It provides visual information from the _______(1).
  • Type: _______(2)
• Oculomotor (III) Cranial Nerve:
  
  • Function: Responsible for the innervation of the _______(3) muscles and the innervation of the _______(4) and _______(5) muscles.
  • Type: _______(6)
• Trochlear (IV) Cranial Nerve:
  
  • Function: It handles the innervation of the _______(7) muscles.
  • Type: _______(8)

Answer 47

Answers:
1. retina
2. Sensory
3. extraocular
4. pupil
5. ciliary
6. Motor
7. superior oblique
8. Motor

“SO 4 LR 6 (ALL REST)3.
SO 4 Late Randy Sex (6) - Till 3

Question 48

Trigeminal (V) Cranial Nerve:
- Ophthalmic branch:
- Lacrimal branch: Innervates the _______(1) glands.
- Frontal branch: Innervates the _______(2) and the medial upper eyelids.
- Nasociliary branch (NIC in the eye): Responsible for the innervation of the _______(3), _______(4), and _______(5).
- Maxillary branch: Deals with the innervation of the _______(6), nasal mucosa, and _______(7).
- Maxine smiles like the SUN (scalp, upper lip, nasal mucosa)
- Mandibular branch: Innervates the _______(8).
- Type: _______(9)/_______(10)

Abducens (VI) Cranial Nerve:
- Function: It handles the innervation of the _______(11) muscles.
- Type: _______(12)

Chatgpt memory device
- “SO 4 LR 6 (ALL REST)3.
- SO 4 Late Randy Sex (6) - Till 3

Facial (VII) Cranial Nerve:
- Function: Responsible for the innervation of the muscles of _______(13).
- Type: _______(14)/_______(15)

Vagus (X) Cranial Nerve:
- Function: Provides _______(16) innervation associated with the oculocardiac reflex.
- Type: _______(17)/_______(18)

Answer 48

Answers:
1. lacrimal
2. forehead
3. ciliary muscles
4. iris
5. corneas
6. upper lip
7. scalp
8. lower jaw
9. Motor
10. Sensory
11. lateral rectus
12. Motor
13. facial expression
14. Motor
15. Sensory
16. parasympathetic
17. Motor
18. Sensory

Question 49

Concerns With Various Ocular Procedures

Procedures and their Associated Concerns:
- Strabismus Repair: Possible sata?
- Concerns: _______(1), OCR (Oculocardiac Reflex), and _______(2) & MH (Malignant Hyperthermia).
- _______(3) is a diagnostic procedure used by ophthalmologists to determine if the movement of the eye is mechanically restricted. During this test, the patient’s eye is numbed with topical anesthesia, and the eye is gently held with forceps.
- The _______(4) is less commonly referenced and is related to the sensation of nausea or vomiting in response to eye movement or pressure. It’s thought to be mediated by connections between the ocular muscles’ sensory innervation and the brainstem areas that control nausea and vomiting.

Intraocular Surgery:
- Concerns: Proper Control of IOP (Intraocular Pressure), Akinesia, potential Drug Interactions, and Associated Systemic Diseases.

Retinal Detachment Surgery:
- Concerns: OCR (Oculocardiac Reflex), Proper Control of IOP (Intraocular Pressure), and the potential interactions with Nitrous Oxide, Sulfur Hexafluoride, or Perfluorocarbons.
- How many days after sulfur hexafluoride can you use nitrous oxide?
- _______(5) days

Answer 49

Answers:
1. Forced Duction Testing
2. Oculogastric Reflex
3. Forced Duction Testing
4. Oculogastric Reflex
5. 10