Nagelhout Ch 43 Flashcards
(420 cards)
1
Q
What mandates anesthetist-surgeon communication in common ENT surgeries?
A
Shared airway.
2
Q
What tools are frequently used in ENT surgeries?
A
Lasers and endoscopes.
3
Q
What are specialized ETTs used in ENT surgeries?
A
Laser and microlaryngeal ETTs.
4
Q
What are the surgical targets in common ENT surgeries?
A
Sinuses, nasal cavity, tonsils/adenoids, oropharynx, larynx, trachea, mandible, maxilla, thyroid, and facial trauma/cancer.
5
Q
What is the function of the nasal cavity?
A
Filter, warm, and humidify inspired air.
6
Q
What is the risk associated with turbinates during nasal intubation?
A
Risk of bleeding due to their highly vascular nature.
7
Q
What causes nasal congestion?
A
Engorgement of mucosal veins leading to swelling of turbinate tissues, reducing nasal cavity space.
8
Q
What are sinuses?
A
Hollow, fragile bones; trauma can cause CSF leak.
9
Q
What is the pharynx?
A
A muscular tube extending from the nasal cavity to the esophagus, ending at C6 vertebral level.
10
Q
What are the components of the pharynx?
A
Nasopharynx, oropharynx, and laryngopharynx (hypopharynx).
11
Q
What is the function of the pharynx in respiration?
A
Conducts air between the nasal cavity and larynx.
12
Q
What is the function of the pharynx in digestion?
A
Muscular constriction allows passage of food to the esophagus.
13
Q
How does the pharynx contribute to phonation?
A
Acts as a resonating chamber for voice production.
14
Q
What happens during swallowing in relation to respiration?
A
Respiration is reflexively inhibited by the medulla oblongata to protect the airway.
15
Q
What is a special consideration for ENT procedures regarding airways?
A
Increased risk of unanticipated difficult airways.
16
Q
What is a potential situation in ENT procedures?
A
Cannot intubate, cannot ventilate situation.
17
Q
What specialized techniques may be used in ENT procedures?
A
Use of specialized ventilation techniques.
18
Q
What is one method of ventilation in ENT procedures?
A
Insufflation.
19
Q
What is a potential occurrence during ENT procedures?
A
Intermittent apnea.
20
Q
What technique can be used to maintain oxygenation during apnea?
A
Apneic oxygenation.
21
Q
What is a safety consideration in ENT procedures?
A
Prevention of endotracheal tube fire.
22
Q
What should be avoided in the surgical field during ENT procedures?
A
Shared airway.
23
Q
What is restricted in ENT procedures regarding anesthesia?
A
Restricted use of nitrous oxide.
24
Q
What is restricted in ENT procedures regarding muscle function?
A
Restricted use of muscle relaxants.
25
What type of equipment is used in ENT procedures?
Use of specialized equipment.
26
What technique may be used for tissue ablation in ENT procedures?
Use of laser for ablation.
27
What ventilation method may be employed in ENT procedures?
High-frequency jet ventilation.
28
What does THRIVE stand for in ENT procedures?
Transnasal humidified rapid-insufflation ventilatory exchange.
29
What condition may be potentially undiagnosed in ENT patients?
Potentially undiagnosed obstructive sleep apnea.
30
What is the pharynx?
The pharynx is a muscular tube extending from the nasal cavity to the esophagus, ending at C6 vertebral level.
31
What are the components of the pharynx?
The pharynx is composed of the nasopharynx, oropharynx, and laryngopharynx (hypopharynx).
32
What is the nasopharynx?
The nasopharynx is continuous with the nasal cavities and extends to the soft palate.
33
What does the oropharynx include?
The oropharynx includes the base of the tongue, soft palate, uvula, and tonsils.
34
What is the laryngopharynx?
The laryngopharynx (hypopharynx) includes the epiglottis and is shared by the respiratory and digestive tracts.
35
What are the functions of the pharynx?
The pharynx has respiratory, digestive, phonation, and swallowing functions.
36
How does the pharynx function in respiration?
It conducts air between the nasal cavity and larynx.
37
How does the pharynx assist in digestion?
Muscular constriction allows the passage of food to the esophagus.
38
What role does the pharynx play in phonation?
It acts as a resonating chamber for voice production.
39
What happens during swallowing?
Respiration is reflexively inhibited by the medulla oblongata during swallowing to protect the airway.
40
What is Waldeyer’s ring?
Waldeyer’s ring is lymphatic tissue encircling the oropharynx.
41
What structures are included in Waldeyer’s ring?
It includes palatine tonsils, adenoids, base of tongue, and soft palate.
42
What are the palatine tonsils?
Palatine tonsils are the most sensitive oropharyngeal structures.
43
What is the blood supply to the pharynx?
The blood supply comes from the external carotid, facial, and maxillary arteries.
44
What can cause hypertrophy of tonsils/adenoids/uvula?
Hypertrophy is often due to chronic infection and can cause airway obstruction, especially in children.
45
What is a risk associated with tonsillectomy?
There is a risk of significant intraoperative/postoperative bleeding due to close proximity to major vessels.
46
What is the function of the epiglottis?
Located in the laryngopharynx; protects the vocal cords during swallowing.
47
How does the epiglottis protect the vocal cords?
Its protective motion depends on superior elevation of the larynx.
48
What is the significance of neuromuscular coordination in swallowing?
Neuromuscular coordination is vital; nerve injury or rigidity increases aspiration risk.
49
Which nerves control the swallowing reflex?
Glossopharyngeal (IX), Superior laryngeal nerve (branch of X), Recurrent laryngeal nerve (RLN, branch of X).
50
What is the role of these nerves in swallowing?
They coordinate glottic closure and protect the airway from food/liquid aspiration.
51
What are the unpaired cartilages of the larynx?
Thyroid, cricoid, epiglottis.
52
What are the paired cartilages of the larynx?
Arytenoid, corniculate, cuneiform.
53
What supports the larynx?
Hyoid bone.
54
What is the primary function of the larynx?
Vocalization and speech articulation.
55
What is a secondary function of the larynx?
Airway protection and respiration.
56
What is the narrowest airway region in adults?
Rima glottidis (vocal cords).
57
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.
58
What are Microcuff tubes recommended for children over 8-10 years?
They improve seal, prevent subglottic edema, and reduce postoperative complications (e.g., croup, stridor).
59
What are the paired cartilages of the larynx?
Arytenoid, Corniculate, Cuneiform
60
What are the unpaired cartilages of the larynx?
Thyroid, Cricoid, Epiglottis
61
What is the sensory nerve that innervates the laryngeal mucosa above the vocal cords?
Superior laryngeal nerve internal branch (vagus)
## Footnote
Innervates the laryngeal mucosa above vocal cords (inferior epiglottis)
62
What is the sensory nerve that innervates the laryngeal mucosa below the vocal cords?
Recurrent laryngeal nerve
## Footnote
Innervates the laryngeal mucosa below vocal cords
63
What is the sensory nerve that innervates the superior aspect of the epiglottis and base of the tongue?
Glossopharyngeal nerve
64
Which motor nerve innervates all intrinsic muscles of the larynx except the cricothyroid?
Recurrent laryngeal nerve
65
Which motor nerve innervates the cricothyroid muscles?
Superior laryngeal nerve external branch
66
What is the function of the Facial Nerve (VII)?
Motor to facial muscles.
67
What are the functions of the Trigeminal Nerve (V)?
Sensory to face, nasal cavity, palate; motor to mastication.
68
What is the function of the Glossopharyngeal Nerve (IX)?
Gag reflex; sensory to posterior tongue and pharynx.
69
What does the Vagus Nerve (X) control?
Includes SLN and RLN; controls vocal cords, airway reflexes.
70
What is the function of the Superior Laryngeal Nerve (SLN)?
Internal branch: sensory above cords. External branch: motor to cricothyroid (affects pitch).
71
What is the function of the Recurrent Laryngeal Nerve (RLN)?
Motor to intrinsic larynx muscles (except cricothyroid); sensory below cords. Injury → hoarseness or stridor.
72
What is the role of the Chorda tympani branch of the Facial Nerve?
Carries taste from the anterior 2/3 of the tongue and innervates submandibular and sublingual glands.
73
What are the divisions of the Trigeminal Nerve (V)?
V1: Ophthalmic, V2: Maxillary, V3: Mandibular.
74
What is the origin of the Trigeminal Nerve?
Gasserian (trigeminal) ganglion.
75
What areas do the Trigeminal Nerve provide sensory and motor innervation to?
Nose, sinuses, palate, and tongue; aids in motor control of the face and mastication.
76
What is the Glossopharyngeal Nerve?
Cranial Nerve IX that provides motor and sensory innervation to the posterior 1/3 of the tongue, nasopharynx, and oropharynx.
77
What reflex does the Glossopharyngeal Nerve elicit?
The gag reflex during stimulation of the posterior pharynx and vallecula.
78
When is the Glossopharyngeal Nerve stimulated?
During airway instrumentation, such as laryngoscopy.
79
What effects can stimulation of the Glossopharyngeal Nerve cause?
May cause bradycardia or gagging.
80
What is the Vagus Nerve?
Cranial Nerve X that has various functions including innervation of the larynx.
81
What is the Superior Laryngeal Nerve (SLN)?
A branch of the vagus nerve at the hyoid level with internal and external branches.
82
What is the function of the Internal branch of the SLN?
Provides sensory innervation above the vocal cords to the glottis via the thyrohyoid membrane.
83
What is the function of the External branch of the SLN?
Provides motor innervation to the cricothyroid muscle, which modulates pitch.
84
What is the Recurrent Laryngeal Nerve (RLN)?
The RLN ascends from the vagus up the distal trachea, passing through the cricothyroid ligament into the proximal trachea and vocal cords.
85
Where does the RLN lie?
The RLN lies between the trachea and esophagus.
86
What is the motor function of the RLN?
The RLN provides motor function to all intrinsic laryngeal muscles except the cricothyroid.
87
What sensory functions does the RLN serve?
The RLN is sensory to the trachea, larynx below vocal cords, and the inferior surface of the epiglottis.
88
How does the RLN affect airway reflexes?
The RLN affects vocal cord closure and sensory function up to the inferior aspect of the epiglottis.
89
What may epiglottic stimulation cause?
Epiglottic stimulation may cause bradycardia, bronchospasm, and hypotension via vagal reflex.
90
What is important to consider during intubation regarding the RLN?
Careful handling of the RLN is required during intubation, especially in pediatrics and patients with vagal hypersensitivity.
91
What is the sensory function of the Superior Laryngeal Nerve (SLN) - Internal?
The SLN - Internal is sensory to the area above the vocal cords and pharynx.
92
What is the clinical relevance of the SLN - Internal?
It is involved in the cough and gag reflex.
93
What is the motor function of the Superior Laryngeal Nerve (SLN) - External?
The SLN - External provides motor function to the cricothyroid muscle.
94
What is the clinical relevance of the SLN - External?
It is important for pitch modulation.
95
What areas does the RLN supply?
The RLN supplies all intrinsic laryngeal muscles (except cricothyroid), below vocal cords, and the trachea.
96
What is the clinical relevance of the RLN?
It is crucial for vocal cord function and there is a risk of hoarseness or stridor if injured.
97
What should CRNAs be cautious of during laryngoscopy or suctioning?
Stimulating the glossopharyngeal or vagus nerve can cause bradycardia.
98
Why is preoperative planning important in ENT surgeries?
Airway is often obstructed or inaccessible once the head is turned/draped.
99
What is a key strategy for securing the endotracheal tube (ETT)?
The ETT may need to be smaller and positioned away from the surgical field.
100
How should the ETT be secured?
Secure firmly using tape or suture, reinforced with transparent occlusive dressings.
101
What should be anticipated post-induction?
Difficult access due to head rotation, draping, suspension laryngoscopes, or retraction systems.
102
What is crucial for anticipating airway difficulty?
Pre-induction airway assessment is essential for planning backup strategies.
103
What should be continuously assessed during ventilation?
Chest movement, auscultation, SpO₂, ETCO₂, and inspiratory pressures.
104
What sudden changes may indicate during ventilation?
Cuff leak, tube obstruction/dislodgement, circuit disconnection, or ETT severance.
105
What additional monitoring tools can be used?
Precordial or esophageal stethoscopes are valuable for detecting subtle airway changes.
106
When is vigilance critical during surgery?
During table rotation, surgical field manipulation, and head repositioning.
107
What should be done to prevent complications during head rotation?
Extend IV lines, breathing circuits, arterial/CVP tubing.
108
How should large-bore IVs and monitors be positioned?
Pre-position them on the side closest to anesthesia.
109
What should be done prior to turning the table?
Preoxygenate with 100% O₂ for 3–5 minutes.
110
What should be temporarily disconnected before turning the table?
Circuit and monitors to avoid tension-related trauma.
111
What should be considered during volatile-only cases?
Adding IV anesthetics to maintain adequate depth during circuit disconnection.
112
What should be reassessed after bed movement?
Tube position, breath sounds and chest expansion, SpO₂, ETCO₂, anesthetic depth.
113
What are the positioning considerations for ENT cases?
ENT cases often require 360° head access by multiple surgical team members and the head draped into the field, which limits access to ETT/circuit.
114
What should be prevented during ENT procedures?
Prevent inadvertent extubation, mainstem migration, and circuit disconnection.
115
What is recommended to prevent pressure injuries?
Use padding to prevent pressure injuries at contact points.
116
How does table tilt affect BP readings?
Table tilt affects BP readings; account for hydrostatic gradient when using noninvasive cuff on leg.
117
When might a surgeon perform a tracheostomy?
A surgeon may perform tracheostomy in difficult or prolonged cases to allow secure airway and prevent ETT interference.
118
What is the characteristic of a tracheostomy ETT?
Tracheostomy ETT is sutured and fixed in position.
119
Where should an arterial line or CVP be placed?
Place on non-operative side or anesthesia-accessible side.
120
How can NIBP be managed?
May use calf to prevent dampened IV flow in upper limbs.
121
What is the alternative for neuromuscular monitoring if hands are inaccessible?
Use tibial nerve (observe big toe flexion).
122
What should be considered for urinary output during long procedures?
Consider Foley catheter for procedures >3 hours or significant fluid shifts.
123
What does a Heat Moisture Exchanger (HME) do?
Reduces insensible water loss during long procedures.
124
What are standard considerations for Endotracheal Tubes (ETTs)?
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.
125
What are RAE Tubes and their ideal uses?
RAE Tubes (Ring-Adair-Elwyn Tubes) have a preformed bend to prevent kinking and keep the tube away from the surgical field.
## Footnote
Ideal uses: Oral RAE for cleft palate repair, tonsillectomy, UPPP, upper face/eye surgery; Nasal RAE for maxillofacial surgery, oral cavity procedures, cosmetic facial surgeries.
126
What precautions should be taken with RAE Tubes?
Must verify proper tube tip position—preformed shape may place tip too proximal/distal, risking endobronchial intubation. Avoid nasal RAE or NG tube placement in facial trauma patients to reduce the risk of intracranial penetration. CT head review is advisable pre-op in facial trauma.
127
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.
## Footnote
Useful in skull base surgery and posterior neck procedures.
128
What is a caution regarding Armored ETTs?
Even edentulous patients may occlude these tubes with oral tissues.
129
What are Laser-Resistant ETTs used for?
Laser-Resistant ETTs contain metal or laser-reflective material to prevent airway fires during laser use (e.g., laryngeal papilloma excision). Cuff is filled with saline (absorbs laser energy) and often mixed with methylene blue to detect cuff rupture.
## Footnote
Important: Do NOT use a wrapped standard ETT with tape as a laser-safe alternative—this increases flammability risk.
130
What is a Laryngeal Mask Airway (LMA) and its uses?
LMA can be used in pharyngeal surgery, as an intubation aid, and for airway rescue.
131
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 (when muscle relaxants are avoided), and isolation of airway from pharyngeal bleeding.
132
What are the contraindications for using an LMA?
Some laryngeal pathologies (e.g., tumors or obstruction).
133
What is the primary use of local anesthetics in ENT surgery?
Especially prevalent in nasal and sinus surgery.
134
How may local anesthetics be administered?
Topically, via injection, combined with IV sedation, MAC, or general anesthesia.
135
What type of agents are primarily used as local anesthetics?
Primarily amide-type agents (e.g., lidocaine, bupivacaine).
136
What is the concentration range for cocaine used in ENT surgery?
Cocaine (4–10%) is used topically in >50% of rhinolaryngologic surgeries.
137
What are the properties of cocaine as a local anesthetic?
Local anesthetic and potent vasoconstrictor.
## Footnote
Metabolized by plasma cholinesterase.
138
What is the duration of action for cocaine?
Duration: ~45 minutes.
139
What is the mechanism of action for cocaine?
Blocks catecholamine reuptake → vasoconstriction and mucosal shrinkage.
140
What are common vasoconstrictors added to local anesthetics?
Epinephrine.
141
What are the common concentrations of epinephrine used?
1:200,000 (5 mcg/mL), 1:100,000 (10 mcg/mL), 1:50,000 (20 mcg/mL).
142
What are the benefits of adding vasoconstrictors to local anesthetics?
Reduces systemic absorption, maintains higher concentration near nerve fibers, extends duration of effect, decreases plasma levels → lowers risk of systemic toxicity.
143
What caution should be taken when using cocaine with epinephrine?
Risk of sympathetic overstimulation → hypertension, tachycardia, dysrhythmias.
144
Who should avoid the combination of cocaine and epinephrine?
Avoid in cardiac patients; consider alternatives (e.g., oxymetazoline).
145
What are anticholinergics used for?
Previously used to reduce secretions from volatile agents. Now selectively used for intraoral surgeries needing a dry field.
146
What is the preferred agent among anticholinergics?
Glycopyrrolate
## Footnote
Less tachycardia vs. atropine and does not cross the blood–brain barrier → no sedation.
147
What is a commonly used corticosteroid?
Dexamethasone.
148
What are the benefits of corticosteroids?
Reduces laryngeal edema, prolongs local anesthetic analgesia, and decreases postoperative nausea and vomiting (PONV).
149
What is the mechanism of corticosteroids?
Reduces inflammation by inhibiting prostaglandins and histamine, and decreases nociceptor sensitivity at surgical sites.
150
What caution should be taken when using corticosteroids?
May suppress immune response and mask infection.
151
What are 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.
152
What mechanisms contribute to PONV in ENT procedures?
Blood in the oropharynx is swallowed, leading to gastric irritation and emesis. Procedures like tonsillectomy are high risk.
153
What preventive measures can be taken to reduce PONV?
Surgical packing in the throat to prevent blood drainage and ensure airway is suctioned, packs removed, and patient is fully awake before extubation.
154
What is recommended for a multimodal antiemetic strategy?
May include ondansetron, dexamethasone, scopolamine, etc.
155
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.
156
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.
157
How does controlled hypotension affect endoscopic sinus surgery (ESS)?
Controlled hypotension improves surgical visibility in the narrow and vascular nasal/sinus field.
158
What is the target MAP for DCH?
Avoid dropping MAP below 50–60 mmHg and do not exceed a 20% reduction from baseline.
159
What must be preserved during DCH?
Cerebral autoregulation, renal perfusion, and coronary blood flow.
160
What special consideration is there for hypertensive patients during DCH?
Chronic hypertension shifts the autoregulation curve, which may necessitate a higher MAP to maintain organ perfusion.
161
What is the purpose of an arterial line in monitoring?
Required for beat-to-beat BP monitoring.
162
Why is urine output monitored?
It serves as a marker of renal perfusion.
163
What is the importance of maintaining MAP above a certain threshold?
It is crucial for brain and kidney safety.
164
What does ABG analysis assess?
Oxygenation, ventilation, and acid-base balance.
165
What is the purpose of cardiac and neuro monitoring?
To maintain perfusion and avoid ischemia.
166
What are examples of β-Blockers?
Esmolol, Labetalol
## Footnote
Benefits: Reduce HR and MAP; preserve perfusion.
167
What is an example of a Calcium Channel Blocker?
Nicardipine
## Footnote
Benefits: Vasodilation without reflex tachycardia.
168
What is an example of an Opioid?
Remifentanil
## Footnote
Benefits: Short-acting; blunts response to stimulation.
169
What are examples of Vasodilators?
Nitroprusside, Nitroglycerin
## Footnote
Benefits: Less precise control; risk of reflex tachycardia or rebound HTN.
170
What is often preferred over single-agent vasodilation?
Combination therapy
## Footnote
Offers better surgical conditions in ESS compared to vasodilators alone.
171
What types of radiation can laser light emit?
Laser light can emit infrared, visible, and ultraviolet radiation.
172
What are the benefits of using lasers in surgery?
Lasers provide precision cutting, minimal bleeding, and reduced tissue trauma/edema.
173
What are common uses of laser surgery in ENT?
Common uses include laryngeal tumor excision, tonsillectomies, and nasal and airway surgeries.
174
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.
175
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.
176
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 for tonsil and nasal surgeries.
177
What are the properties and common uses of Argon Laser?
Argon Laser emits blue-green light and is used in ophthalmology and ENT.
178
What are the properties and common uses of KTP Laser?
KTP Laser is made of potassium titanyl phosphate and emits a green wavelength. It is used for soft tissue procedures, such as nasal polyps.
179
What is the definition of monochromatic light?
One wavelength.
180
What does it mean for laser light to be coherent?
It oscillates in the same phase, or all the photons are moving in the same direction.
181
What does collimated light refer to?
A parallel beam that is focused and narrow.
182
What are the tissue effects of laser light?
Cutting, coagulation, and vaporization depend on tissue type, laser wavelength, beam power, and duration.
183
What factors contribute to airway fires during laser procedures?
Oxygen-rich environment, presence of combustible materials (ETT), and laser beam ignition source.
184
What is the incidence rate of airway fires?
~0.4%.
185
What can positive pressure ventilation during a laser strike cause?
A blowtorch effect.
186
What is a prevention strategy for airway fires?
Use laser-resistant ETT, avoid N₂O, maintain FiO₂ < 30%, and fill cuff with methylene blue–dyed saline.
187
What does a saline-filled cuff do in an ETT?
It absorbs heat and the dye signals a leak.
188
What should be avoided to prevent combustion in ETTs?
Avoid air-filled cuffs; saline acts as a fire suppressant.
189
What type of goggles should be used for laser protection?
Laser-specific goggles: green lenses for Nd:YAG, orange-red for KTP, clear for CO₂.
190
What is the purpose of smoke evacuators?
To remove toxic smoke (plume) at the vaporization site, especially for viral papilloma or cancer.
191
What are the key components of operating room policies for laser safety?
Adhere to standardized protocols including fire drills, trained staff, and visible signage.
192
What must an ideal laser-resistant ETT provide?
Ventilation, laser protection, and low fire risk.
193
What features should an ideal laser-resistant ETT have?
Metal wrapping or impregnation and cuff inflation with saline + methylene blue.
194
What should be avoided when using standard ETTs?
Avoid wrapping standard ETTs with reflective tape as it is not effective and flammable.
195
What are the types of endoscopy used in ENT?
Rigid or flexible endoscopes are used for panendoscopy, laryngoscopy/microlaryngoscopy, bronchoscopy, esophagoscopy, and endoscopic sinus surgery (ESS).
## Footnote
ESS is the most common, with over 250,000 performed annually in the U.S.
196
What are the preoperative considerations for endoscopic procedures?
Considerations include assessing for complications like eye trauma, epistaxis, laryngospasm, and bronchospasm, as well as airway evaluation and premedication.
## Footnote
Anxiolytics and antisialagogues may be used, and caution is advised with sedatives.
197
What is awake intubation?
Awake intubation involves minimal sedation and topical anesthesia of the oral cavity, pharynx, larynx, and nasopharynx. In rare cases, awake tracheostomy may be performed.
198
What is the purpose of maintaining anesthesia with short-acting agents in shorter ENT procedures?
To avoid patient movement and vocal cord movement, and to control sympathetic nervous system response during brief periods of extreme stimulation.
199
What is a Microlaryngeal ETT?
A Microlaryngeal ETT (size 5.0–6.0) has a larger cuff for better airway security and ventilation monitoring.
## Footnote
Advantages include secure airway and controlled ventilation, while disadvantages include possible interference with the surgical field.
200
What is the Intermittent Apnea Technique?
This technique involves the anesthetist or surgeon removing the ETT, operating during a brief apnea, and then reintubating the patient.
## Footnote
Risks include desaturation and airway unprotected during apneic periods.
201
What are the considerations for muscle relaxation and sedation in ENT procedures?
Adequate muscle relaxation is essential; succinylcholine is used for short cases, while intermediate NMBs are used for longer cases.
## Footnote
Remifentanil infusion is preferred if vocal cord monitoring is needed.
202
What should be ensured during emergence and PACU?
Thorough suctioning, humidified oxygen, and monitoring for laryngospasm, post-extubation croup, and stridor should be ensured.
203
What is jet ventilation?
Jet ventilation is used in laryngeal surgery where ETT obstructs the surgical view, involving a needle catheter delivering high-pressure O₂.
## Footnote
It can be difficult to maintain oxygenation in certain patients.
204
What are the modes of jet ventilation?
Modes include supraglottic (above vocal cords), infraglottic (below vocal cords), transtracheal (through cricothyroid membrane), and via bronchoscope (inside rigid bronchoscope).
205
What are the safety measures for jet ventilation?
Use FiO₂ ≤ 30% to reduce fire risk, monitor chest rise, precordial stethoscope, and pulse oximetry, and use IV anesthetics only.
206
What are the risks and contraindications of jet ventilation?
Risks include air trapping/barotrauma and misplaced jet leading to gastric insufflation. Contraindicated in full stomach, hiatal hernia, and trauma.
## Footnote
Poor expiration can occur in patients with bronchospasm, obesity, or COPD.
207
What does THRIVE stand for?
Transnasal Humidified Rapid-Insufflation Ventilatory Exchange
208
What is THRIVE used for?
To extend apneic oxygenation time in patients with minimal or absent respiratory effort.
209
What flow rate does THRIVE deliver oxygen at?
10–12 L/min or higher.
210
What type of oxygenation does THRIVE provide?
Passive oxygenation—prolongs safe apnea window.
211
What is a useful alternative to jet ventilation?
THRIVE.
212
Who is most commonly affected by foreign body aspiration?
Children under 4 years old.
213
What are the leading causes of foreign body aspiration in children?
Nuts & seeds, small toys, hot dogs, bits of meat, coins.
214
Which bronchus is the most common site for foreign body aspiration?
Right bronchus due to vertical orientation.
215
What happens if the patient is supine during foreign body aspiration?
Gravity causes the object to enter the right upper lobe bronchus.
216
What happens if the patient is upright during foreign body aspiration?
The foreign body is more likely to settle in the right lower lobe.
217
What are common clinical presentations of foreign body aspiration?
Wheezing, coughing, choking, aphonia, tachycardia, cyanosis.
218
What should you suspect if sudden respiratory distress occurs?
Aspiration.
219
What tools are used for the diagnosis of foreign body aspiration?
CT, flexible/rigid bronchoscopy, virtual bronchoscopy.
220
What is the gold standard for diagnosis and treatment of foreign body aspiration?
Rigid bronchoscopy.
221
What factors influence anesthetic management in foreign body aspiration?
Location of airway, size of object, and obstruction severity.
222
What is the recommended approach for an object in the larynx?
Direct laryngoscopy + Magill forceps under topical anesthesia.
223
What is the recommended approach for an object in the distal airway/trachea?
Spontaneous breathing induction with inhalation agent + rigid bronchoscopy.
224
What should be considered in cases of severe obstruction?
Awake tracheostomy or rigid bronchoscopy in OR.
225
What should be prepared for in a full stomach scenario?
RSI and complete occlusion risk.
226
What should be avoided before airway is secured?
Positive pressure ventilation (PPV).
227
What position should be used to reduce airway compromise?
Sitting position.
228
What medications should be pre-medicated with to decrease secretions?
Antisialagogues (e.g., glycopyrrolate), H2 antagonists, Metoclopramide.
229
What is the preferred anesthesia technique for rigid bronchoscopy?
Total IV Anesthesia (TIVA).
230
What are the benefits of using TIVA?
Cardiovascular stability, allows quick titration, minimizes airway stimulation.
231
What should be used during anesthesia for rigid bronchoscopy?
100% O₂.
232
What should be avoided in the operating room during anesthesia?
Volatile agents.
233
What are some airway complications during foreign body aspiration management?
Laryngospasm, bronchospasm, tracheal/bronchial laceration.
234
What are some respiratory complications during foreign body aspiration management?
Hypoxia, hypercarbia, barotrauma, pneumothorax, pneumomediastinum.
235
What are some cardiac complications during foreign body aspiration management?
Hypoxic cardiac arrest, dysrhythmias, vagal stimulation from head extension.
236
What are some mechanical complications during foreign body aspiration management?
Dental trauma, lip/gum injury.
237
What are some neurologic complications during foreign body aspiration management?
Hypoxic brain injury from inadequate ventilation.
238
What type of edema may occur postoperatively?
Laryngeal or subglottic swelling.
239
What should be ensured before extubation?
Return of consciousness and protective airway reflexes.
240
What treatments may be used postoperatively as needed?
Humidified oxygen, racemic epinephrine, steroids, and bronchodilators.
241
What may be necessary if significant airway edema occurs postoperatively?
Postoperative intubation and sedation.
242
What test may help assess airway patency before extubation?
Cuff leak test.
243
What are common procedures in anesthesia for face, ear, head, and neck?
Myringotomy with tube insertion, tympanoplasty, mastoidectomy, stapedectomy, acoustic neuroma.
244
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).
245
Which nerves are commonly monitored during these procedures?
Facial nerve (CN VII), vagus (CN X), recurrent/inferior laryngeal nerves (CN X), spinal accessory nerve (CN XI).
246
What monitoring techniques are used for nerve monitoring?
Electromyography (EMG), brainstem auditory-evoked potentials, electrocochleography.
247
What is the guidance for using muscle relaxants?
Only for induction/intubation, then avoid to preserve nerve responses.
248
What is the guidance for using local anesthetics?
Contraindicated; avoid at nerve sites as they suppress EMG signal amplitude.
249
What is essential for movement prevention during these procedures?
Use opioid infusions (e.g., remifentanil, sufentanil).
250
What is the guidance regarding volatile agents and N₂O?
Acceptable with caution; discontinue N₂O before middle ear closure.
251
What should be considered during emergence from anesthesia?
Consider deep extubation to avoid coughing and bleeding.
252
How does midazolam help preoperatively?
Helps assure amnesia and rapid emergence.
253
What is the middle ear?
An air-filled cavity housing 3 ossicles: malleus, incus, and stapes, connected to the nasopharynx by the eustachian tube.
254
What is the significance of the facial nerve in relation to the middle ear?
It traverses the middle ear and exits via the stylomastoid foramen.
255
What are the common adult surgeries in this context?
Tympanoplasty, stapedectomy, mastoidectomy, ossiculoplasty.
256
What are the pediatric surgeries commonly performed?
Myringotomy with tube insertion, tympanoplasty, grommet insertion, cochlear implants.
257
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 under drapes.
258
What is a primary problem at the beginning of surgery?
Pain from multiple injections of local anesthetic with epinephrine.
259
What can increase patient comfort during surgery?
Topical lidocaine and prilocaine (eutectic mixture of local anesthetics [EMLA]).
260
What should be avoided after intubation for facial nerve monitoring?
Avoid neuromuscular blockers.
261
What is important for PONV prevention?
Use multimodal antiemetic prophylaxis and avoid agents that increase inner ear pressure (e.g., N₂O near case end).
262
What are techniques to reduce bleeding?
Bloodless field is essential; physical and pharmacologic techniques are used.
263
What are some physical techniques to reduce bleeding?
Head elevation (15–20°), avoid venous obstruction, normocapnia, controlled hypotension (SBP 80–90 mmHg or ↓ 20% of baseline MAP).
264
What are some pharmacologic techniques to reduce bleeding?
Volatile anesthetics, beta-blockers (labetalol, esmolol), α2-agonists (dexmedetomidine), opioids (remifentanil), magnesium sulfate (recent adjunct).
265
What is the role of dexmedetomidine?
Reduces BP and HR, provides sedation without respiratory depression, blunts sympathetic response.
266
What should be avoided during emergence and recovery?
Coughing, straining, or bucking to prevent prosthesis displacement and minimize postoperative bleeding.
267
What should be considered for deep extubation?
Consider if there are no contraindications.
268
What is typically done postoperatively regarding the head?
The head is typically bandaged.
269
What should be ensured during emergence?
Smooth emergence with airway reflexes intact.
270
How soluble is Nitrous Oxide (N₂O) compared to nitrogen in blood?
N₂O is 34 times more soluble than nitrogen in blood.
271
What happens to middle ear pressure if the eustachian tube is obstructed during anesthesia?
N₂O enters faster than nitrogen leaves, increasing middle ear pressure.
272
How can positive pressure ventilation affect middle ear pressure?
It can further elevate middle ear pressure by forcing gas through the eustachian tube.
273
What is the effect of N₂O during tympanoplasty when the middle ear is open?
N₂O has no significant effect.
274
What can happen if N₂O is used after tympanic membrane graft placement?
Continued use of N₂O can increase pressure and cause graft displacement, and on discontinuation, rapid absorption may lead to negative pressure, serous otitis media, stapes disarticulation, and impaired hearing.
275
What is the guideline for using N₂O during tympanoplasty?
Avoid N₂O entirely during tympanoplasty to prevent pressure shifts that could displace grafts.
276
When should N₂O be discontinued before graft placement?
Discontinue N₂O ≥15 minutes before graft placement to allow middle ear pressure to normalize.
277
Why should N₂O be avoided in high PONV-risk patients?
N₂O increases PONV, which is already high in ear surgery.
278
What is the goal of myringotomy?
To equalize pressure by making a small incision in the tympanic membrane.
279
What are the indications for myringotomy?
Relief of middle ear pressure/fluid due to chronic serous otitis media or recurrent otitis media.
280
What is the goal of surgery for middle ear conditions?
To ventilate the middle ear and prevent hearing loss, speech delay, or permanent ear damage.
281
Is premedication usually needed for myringotomy?
Usually not needed as it may outlast the procedure.
282
What is the preferred induction method for myringotomy?
Mask induction with sevoflurane + O₂ ± N₂O.
283
What is the preferred airway management for uncomplicated cases?
Use mask or LMA.
284
What should be done in case of an anticipated difficult airway?
Consider ETT, though rarely needed.
285
What is the average blood loss during tonsillectomy?
Average loss is approximately 4 mL/kg or ~5% of blood volume.
286
What are the common airway challenges during tonsillectomy?
Obstruction, laryngospasm, and post-extubation stridor.
287
What is the preferred airway device for pediatric patients?
LMA or cuffed ETT for uncomplicated cases.
288
What is the goal of anesthesia maintenance during tonsillectomy?
To achieve deep anesthesia, stable hemodynamics, rapid return of protective reflexes, minimize bleeding, and reduce PONV.
289
What is the position for patients post-tonsillectomy?
Side-lying, head down in kids, Fowler in adults post-UPPP.
290
What is the risk of posttonsillectomy hemorrhage (PTH)?
Occurs in 0.5–7.5% of cases and is the most common emergency pediatric airway surgery.
291
What is the timing of bleeds post-surgery?
Within 6 hours: ~75%
6–24 hours: ~25%
Up to Day 6: Less common, but possible
292
What is the clinical presentation of bleeding?
More common: Slow oozing > profuse bleeding. Swallowed blood may cause nausea, vomiting, and obscure airway visualization.
293
What are signs of hypovolemia?
Tachycardia, hypotension, restlessness/agitation.
294
What should be assessed in cases of bleeding?
Always assess hemodynamics and history.
295
What labs are needed for preoperative preparation?
Hemoglobin & hematocrit, coagulation profile.
296
What is the resuscitation approach before induction?
Restore volume first: IV fluids and blood products before induction if needed.
297
What is a key consideration for anesthesia induction in high aspiration risk?
Assume stomach is full of blood.
298
What induction method is recommended for high aspiration risk?
Rapid Sequence Induction (RSI).
299
What should be done during induction regarding suctioning?
An additional person should suction oropharynx during induction.
300
What positioning is recommended during induction?
Slight Trendelenburg (head-down) to protect trachea & glottis from aspiration.
301
What should be avoided during laryngoscopy?
Avoid clot disruption; gentle laryngoscopy; preserve clot when possible; awake intubation may be necessary.
302
What are the intubation options for patients with specific conditions?
RSI is standard. Awake intubation may be necessary in patients with full stomach, unstable hemodynamics, or compromised airway anatomy or massive bleeding.
303
What is the purpose of gastric decompression (OGT/NGT) in intraoperative management?
Assess blood loss, reduce aspiration risk.
304
What is essential for suction setup during surgery?
May need multiple suction lines.
305
What should be ready for transfusion during surgery?
Crossmatched blood and fluids.
306
What is the goal for airway protection during emergence and recovery?
Extubate only after full return of protective airway reflexes.
307
What should be confirmed before reversal/extubation?
Confirm surgical hemostasis.
308
How should PONV be managed?
Treat aggressively due to risk of aspiration from swallowed blood.
309
What are common indications for thyroid surgery?
Thyrotoxicosis (e.g., Graves' disease), thyroid malignancy (most commonly papillary or follicular), large goiters causing airway compression.
310
What are the surgical approaches for thyroid surgery?
Open, minimally invasive, or robotic-assisted.
311
What is the largest endocrine gland and its characteristics?
Butterfly-shaped gland, anterior to the trachea and just below the larynx; connected by thyroid isthmus; extremely vascular (blood flow is ~5× gland weight).
312
What nerves are in close anatomical proximity to the thyroid?
Intrinsic Recurrent laryngeal nerve (RLN) and external branch of superior laryngeal nerve.
313
What can injury to the recurrent laryngeal nerve result in?
Airway obstruction post-extubation.
314
What risks are exacerbated by sympathetic nervous system hyperactivity due to excess thyroid hormone?
Tachyarrhythmias, hypertension, thyroid storm.
315
What is thyrotoxicosis?
Excess circulating thyroid hormone (any cause).
316
What is hyperthyroidism?
Thyrotoxicosis due to increased thyroid production.
317
What is the most common cause of thyrotoxicosis?
Graves' disease.
318
What are the most common thyroid malignancies?
Papillary thyroid cancer (PTC) and follicular thyroid cancer (FTC).
319
What is the prognosis for papillary thyroid cancer?
Usually presents at an early stage and has an excellent prognosis (>95% 10-year survival).
320
What is the prognosis for follicular thyroid cancer?
Tends to present at a later stage than PTC; 10-year survival rate for FTC is 85%.
321
What are the primary goals of thyroid surgery?
1. Ensure euthyroid state 2. Evaluate airway anatomy and function 3. Assessment of end-organ complications.
322
What medications should continue on the morning of surgery for hyperthyroid patients?
Antithyroid drugs (e.g., methimazole, PTU), beta-blockers (e.g., propranolol for symptom control), and steroids (may need stress dose).
323
What are the anesthetic implications of increased β-adrenergic activity in hyperthyroidism?
Tachycardia, arrhythmias, and increased oxygen demand.
324
What should be considered regarding muscle relaxants in hyperthyroid patients?
Increased incidence of myasthenia gravis and sensitivity to muscle relaxants; consider reduced NMBA dosing.
325
What is the risk associated with hyperthyroidism during anesthesia?
Risk of thyroid storm, which is rare but potentially life-threatening.
326
What potential airway issues can arise in patients with large goiters?
Compression or deviation of the trachea, tracheomalacia, and narrowing of the airway lumen leading to difficult ventilation or intubation.
327
What should be included in the pre-induction assessment for airway evaluation?
Examine airway in supine position, check for voice changes, dysphagia, stridor, and consider CT neck/chest or bronchoscopy if significant compression.
328
What is the management for a normal airway during induction?
RSI or standard induction with ETT.
329
What should be considered for tracheal compression or goiter during induction?
Consider awake fiberoptic intubation.
330
What is the risk associated with tracheomalacia during extubation?
Risk of collapse after extubation; may need delayed extubation or tracheostomy.
331
What anesthetic technique is recommended for intraoperative management in hyperthyroid patients?
General anesthesia with ETT.
332
What is the recommendation regarding nerve monitoring during surgery?
Avoid long-acting NMBAs to allow intraoperative EMG monitoring of RLN/superior laryngeal nerve.
333
What is critical regarding blood loss during thyroid surgery?
Moderate blood loss is expected; suction and visualization are critical.
334
What is the purpose of the Medtronic NIM 3.0 EMG Tube in thyroid surgery?
To monitor RLN and vocal cord function intraoperatively via electromyography (EMG).
335
What are the potential consequences of RLN injury?
Hoarseness, aphonia, and rarely, bilateral cord adduction leading to airway obstruction.
336
What are the features of the NIM 3.0 ETT?
Silicone elastomer tube with inflatable cuff, four stainless steel electrodes, and connects to a four-channel EMG system.
337
What is the recommended patient positioning for using the NIM 3.0 ETT?
Supine with neck extension, head elevated ~30° with a roll under shoulders, arms tucked and ulnar nerves padded.
338
What should be avoided to protect EMG integrity during surgery?
Long-acting neuromuscular blockers, lidocaine on cords, and indirect vasopressors like ephedrine.
339
What is the preferred vasopressor for hypotension in hyperthyroid patients?
Use direct-acting agents like phenylephrine.
340
What should be ensured during emergence and postoperative management?
Ensure full return of vocal cord function (check for hoarseness, stridor)
341
What are the signs to be alert for during emergence?
RLN injury → hoarseness, stridor, airway collapse; Hypocalcemia from parathyroid injury → laryngospasm, tetany
342
What are the most common postoperative complications?
Hypocalcemia, RLN damage, and hematoma at the surgical site.
343
What should be monitored postoperatively?
Voice assessment, airway patency, signs of hematoma, calcium levels, and continue beta-blockers and antithyroid meds as indicated.
344
What causes hypocalcemia due to parathyroid injury?
Inadvertent removal, devascularization, or stunning of the parathyroid glands during thyroidectomy.
345
What is the pathophysiology of hypocalcemia?
Decreased parathyroid hormone (PTH) → decreased serum calcium → increased neuromuscular excitability.
346
When does hypocalcemia typically appear postoperatively?
Typically appears 24-96 hours postoperatively.
347
What are mild to moderate symptoms of hypocalcemia?
Perioral numbness, paresthesias, abdominal pain, carpopedal spasm, mental status changes.
348
What are severe symptoms of hypocalcemia?
Laryngospasm, tetany, seizures, cardiac arrest, prolonged QT interval.
349
What are clinical signs of hypocalcemia?
Chvostek sign: facial twitching when tapping over the facial nerve; Trousseau sign: carpal spasm with BP cuff inflation.
350
How should symptomatic hypocalcemia be treated?
10 mL of 10% calcium gluconate or calcium chloride IV over several minutes; Continuous infusion of calcium at 1–2 mg/kg/hr.
351
What is the incidence of recurrent laryngeal nerve (RLN) injury?
Occurs in up to 14% of cases.
352
What is essential to avoid RLN injury during surgery?
The surgical identification and preservation of the RLN.
353
What is the presentation of unilateral RLN injury?
Ipsilateral vocal cord paralysis (cord remains midline) → hoarseness, weak voice.
354
What is the presentation of bilateral RLN injury?
Both cords remain midline → glottic obstruction → stridor, aphonia, respiratory distress post-extubation.
355
What is the anesthesia management for unilateral RLN injury?
Monitor voice; typically non-emergent.
356
What is the anesthesia management for bilateral RLN injury?
Requires immediate intervention: Emergent reintubation or tracheotomy; Biphasic stridor is a key indicator.
357
What causes neck hematoma as an airway emergency?
Postoperative bleeding compressing the airway.
358
What are early signs/symptoms of neck hematoma?
Neck swelling or pressure, neck pain.
359
What are severe signs/symptoms of neck hematoma?
Dyspnea, stridor, asphyxiation, rapid airway compromise.
360
What is the management for neck hematoma?
Surgical emergency; Immediate evacuation of hematoma (sutures may need to be cut at bedside).
361
What is the incidence of cleft palate and cleft lip repair?
One of the most common congenital craniofacial anomalies (~1:700 births).
362
What are the components of clefts?
Clefts may involve lip, hard palate, soft palate, or a combination.
363
What syndromes are associated with cleft palate and cleft lip?
Down, Pierre Robin, Treacher Collins.
364
When should cleft lip be repaired?
Repair at ~3 months (with tip rhinoplasty).
365
When should cleft palate be repaired?
Repair at 5–8 months to support normal speech development.
366
What is the 'Rule of 10s' for surgical timing?
Age >10 weeks, Weight >10 lb, Hemoglobin >10 g/dL, WBC <10,000.
367
What are airway considerations for cleft palate repair?
Difficult intubation risk due to cleft anatomy; Pack cleft with gauze to prevent blade slippage; Use oral RAE ETT, secured midline to lower lip.
368
What should be avoided in patients with congenital heart disease during cleft repair?
Avoid IV air bubbles.
369
What are postoperative considerations for cleft palate repair?
Tongue-lip suture often placed to prevent obstruction; Avoid oral airways post-repair.
370
What is critical before extubation in cleft palate repair?
Ensure a clear airway before extubation; Fully awake extubation with intact reflexes is critical.
371
What are the indications for dental restoration under anesthesia?
Extensive dental disease, developmental delay, cerebral palsy, Down syndrome, or behavioral non-cooperation.
## Footnote
Have someone familiar to accompany.
372
What should be evaluated for airway management in dental restoration?
Small mouth, large tongue, high secretions, enlarged tonsils, atlantoaxial instability, congenital heart disease.
373
What is a consideration for nasal intubation?
Consider using a topical vasoconstrictor spray.
374
What is the recommended premedication for sedation/induction?
Midazolam (0.5 mg/kg PO) or Ketamine (3–4 mg/kg IM).
375
What should be monitored during dental restoration under anesthesia?
Monitor for gingival bleeding, especially in phenytoin users due to gingival hyperplasia.
376
What are common indications for sinus and nasal surgery?
Chronic sinusitis, nasal polyps, deviated septum, facial fractures, chronic environmental and drug allergies.
377
What anesthesia techniques are used in sinus and nasal surgery?
Local ± sedation, or general anesthesia.
378
What agents are used for vasoconstriction in sinus and nasal surgery?
Epinephrine, cocaine, phenylephrine.
379
What are the blood loss considerations during sinus and nasal surgery?
General anesthesia, especially volatile agents, increases bleeding risk. Propofol-based TIVA is associated with less blood loss.
380
What should be done prior to extubation in sinus and nasal surgery?
Remove all packing and suction the stomach to reduce PONV.
381
What are the airway threats in facial/neck trauma?
Edema, bleeding, fractures, lacerations, foreign bodies, disruption of nasal passages or pharynx.
382
What is the airway strategy for trauma?
Assess C-spine, use manual inline stabilization or a rigid cervical collar.
383
What are the red flags for trauma management?
Blistering/burns around mouth/nose, Le Fort II & III fractures, suspected basal skull fracture.
384
What is the risk associated with Le Fort II fractures?
Risk of cribriform plate injury; avoid nasal ETT.
385
What should be avoided in Le Fort III fractures?
Avoid nasal ETT due to risk of intracranial entry.
386
What are key practices in maxillofacial and orthognathic surgery?
Secure the airway safely, prepare for difficult airway, use nasal ETT for IMF procedures.
387
What signs indicate a basal skull fracture?
CSF rhinorrhea, blood behind tympanic membrane, periorbital edema, 'raccoon eyes.'
388
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.
389
What does orthognathic surgery include?
Orthognathic surgery includes sagittal split osteotomy (mandible) and Le Fort osteotomies (maxilla).
390
Why is orthognathic surgery common?
It is common in congenital facial anomalies, which can lead to difficult airways.
391
What type of endotracheal tube (ETT) is preferred in orthognathic surgery?
Nasal ETT is preferred.
392
What should be prevented during orthognathic surgery?
Prevent nares necrosis from ETT positioning.
393
What technique is used for blood loss control in orthognathic surgery?
Deliberate hypotension is used for blood loss control if hemodynamically stable.
394
What may be required for rigid fixation in orthognathic surgery?
Cutting tools should be available for emergency airway access.
395
When should delayed extubation be considered?
Consider delayed extubation if edema is significant.
396
What are the extubation criteria in orthognathic surgery?
Extubation criteria include being awake, having full protective reflexes, and continuous monitoring.
397
What tools should be included in the emergency management checklist for orthognathic surgery?
Wire cutters at bedside, oral and nasal airway adjuncts, tracheostomy/cricothyrotomy set, blood products crossmatched and ready, emergency drugs and vasopressors available, suction equipment functional and accessible.
398
When is radical neck dissection required?
It is required when cancerous tumors invade musculature and other structures of the head & neck.
399
What are common comorbidities associated with radical neck dissection?
Common comorbidities include smoking, alcohol use, COPD, cardiovascular disease, and prior radiation therapy.
400
What nutritional concerns arise from radical neck dissection?
Tumor-related dysphagia may lead to malnutrition, dehydration, anemia, and electrolyte imbalance.
401
What are the airway risks associated with radical neck dissection?
Tumors may bleed easily and distort anatomy, potentially causing hemorrhage or edema during intubation.
402
What are the types of flaps used in reconstruction?
Types of flaps include regional pedicle flaps (e.g., pectoralis major myocutaneous flap, trapezius flap, forehead rotational flap) and free tissue transfer (microvascular flaps) such as small bowel grafts.
403
What is the goal of flap surgery?
The goal is maintaining stable hemodynamics, supporting microvascular perfusion, and avoiding vasoconstriction, overhydration, and hypoperfusion.
404
What lines are recommended for monitoring and vascular access?
Recommended lines include arterial line for continuous BP + ABG monitoring, Foley catheter for fluid and urine output monitoring, and a CVP line avoiding internal jugular vein.
405
What is the anesthesia maintenance strategy for orthognathic surgery?
Use inhalation agents + supplemental opioids and avoid depolarizing muscle relaxants if nerve monitoring is in use.
406
What should be avoided in fluid management during surgery?
Avoid fluid overload, as excess fluids can cause flap edema and vascular compromise.
407
What is required for surgical coordination in airway management?
Advance ETT to just above tracheal incision and ensure the new airway is secure before removing ETT.
408
What are the anesthetic steps for intraoperative tracheostomy or laryngectomy?
Pre-transection preparation includes fully oxygenating the patient, advancing ETT above the incision, and suctioning the airway. The surgeon then transects the trachea and places a reinforced ETT.
409
What may carotid sinus manipulation cause?
Vagal Reflexes: Bradycardia, Hypotension, Cardiac arrest.
410
What are preventative strategies for carotid sinus manipulation?
Local anesthetic to carotid sinus and Anticholinergics (e.g., glycopyrrolate or atropine).
411
What is the risk associated with venous air embolism (VAE)?
Due to head-up position and open neck veins.
412
How can venous air embolism (VAE) be detected?
Use precordial Doppler or TEE for detection.
413
What is critical in the management of venous air embolism?
Immediate aspiration of air via CVP line.
414
Why is ICU admission recommended postoperatively?
Due to fluid/electrolyte shifts, altered ventilation-perfusion dynamics, and long anesthetic duration.
415
What complications should be monitored postoperatively?
Tracheostomy care, laryngeal edema, flap congestion, and pulmonary issues (pneumothorax, hemothorax, pulmonary edema).
416
What is the risk associated with surgical wounds?
Hematoma risk with potential for airway obstruction, requiring emergent evacuation if present.
417
What happens to the reinforced tube at the end of the case?
It is typically exchanged for a tracheostomy cannula.
418
What is the agent selection for anesthesia maintenance?
Inhalational agents + supplemental opioids (e.g., remifentanil).
419
What should be avoided after intubation if nerve monitoring is needed?
Depolarizing agents.
420
What type of vasopressors should be used for hypotension?
Direct-acting vasopressors (phenylephrine) rather than indirect ones (ephedrine) due to catecholamine stimulation risk.
