Test 3: HEENT (PT 1/2)

Question 1

Which part of the nasal cavity is highly vascular and may lead to severe bleeding?

Answer 1

Turbinates

Question 2

What are the functions of the larynx?

Answer 2

vocalization/articulation & protection of airway/allows respiration

Question 3

What is innervated by the Internal Branch of the Superior Laryngeal Nerve?

Answer 3

laryngeal mucosa above vocal cords (inferior epiglottis

Question 4

What is Sensory innervated by the Recurrent Laryngeal Nerve?

Answer 4

laryngeal mucosa below vocal cords

Question 5

What is innervated by the Glossopharyngeal Nerve?

Answer 5

-superior aspect of epiglottis & base of tongue
-Motor + sensory for base of tongue, nasopharynx, & oropharynx
-Responsible for eliciting the gag reflex

Question 6

What is innervated by the External Branch of the Superior Laryngeal Nerve?

Answer 6

Motor to the cricothyroid muscles (adduction-tension/elongation VC))

Question 7

What is Motor innervated by the Recurrent Laryngeal Nerve?

Answer 7

all intrinsic muscles except cricothyroid (lots of actions)

Question 8

What does the Facial Nerve supply innervation to?

Answer 8

motor and sensory supply to the muscles for facial expressions

Question 9

What does the Trigeminal Nerve supply innervation to?

Answer 9

3 Branches: ophthalmic, maxillary, mandibular
sensory & motor to the nose, sinuses, palate, and tongue. Aid in motor control of face & in mastication

Question 10

The RLN & SLN lie in close proximity to the _____

Answer 10

lateral lobe of the thyroid gland

Question 11

What supplies innervation to the 6 extraocular muscles?

Answer 11

innervation by CN3 except SO4 LR6

Question 12

How do you deal with the Shared Airway in ENT surgery?

Answer 12

-Requires planning and effective communication
-Maintenance of adequate ventilation and security/patency of ETT
-Constantly assess adequacy of ventilation (observe chest excursion, auscultation, SpO2, EtCO2, inspiratory pressures)
-Bubbling noises or smell of anesthetic gas = ETT cuff problem or migration above the vocal cords
-Surgeons may request periods of apnea, jet ventilation, or spontaneous respiration (may be difficult to maintain TIVA)
-Surgeons may insert throat packs to prevent blood/debris aspiration
-Must document time of insertion & removal!

Question 13

Explain Deliberate Controlled Hypotension

Answer 13

-Reduce MAP to reduce blood loss
-Maintain MAP around 60mmHg or 20% decrease from baseline (chronic htn may require a higher MAP)
-Must maintain cerebral + renal autoregulation as well as coronary blood flow
-Arterial BP monitoring = required!

Question 14

What agents are used to produce deliberate, controlled hypotension?

Answer 14

Vasodilating agents, BB, CCB, ultrashort-acting opioids (remifentanil), inhalational agents

Question 15

What are the local anesthetics used in ENT surgery?

Answer 15

(most common = amide-based drugs)
Cocaine, Lidocaine, Benzocaine, Bupivacaine, Mepivacaine, Dyclonine
Common in nasal/sinus surgery. Topical/local anesthesia may be sole agent

Question 16

What is the only local anesthetic with vasoconstrictive ability?

Answer 16

Cocaine (blocks catecholamine reuptake)

Question 17

What vasoactive meds are commonly used in ENT surgery?

Answer 17

-Epinephrine: May be added to local anesthetic solutions to produce vasoconstriction
-Prolongs DOA of LA & decreases systemic absorption

Question 18

What anticholinergic meds are used in ENT surgery?

Answer 18

Used for antisialagogue effects (dry secretions)
-Glycopyrrolate = better choice than atropine bc less tachycardia. Glyco does not cross BBB so no sedation

Question 19

Why are corticosteroids used in ENT surgery?

Answer 19

-Ex: Dexamethasone
-Decrease laryngeal edema, reduce N/V, prolong analgesia of LA
-Administer as early as possible to reach peak prior to surgery

Question 20

What PONV prophylaxis is used in ENT surgery?

Answer 20

-5HT3 antagonists (ondansetron)
-Dexamethasone
-TIVA vs inhalational (avoid N2O)
-Multimodal Pain mgmt/opioid sparing

Question 21

What is important to know about throat packs?

Answer 21

-Must document insertion & removal time
-Throat packs placed to prevent blood from entering the stomach causing N/V
-Used in a variety of settings…dental, cleft lip/palate

Question 22

Detail positioning concerns regarding ENT surgery?

Answer 22

-Head is prepped, draped, or wrapped in towels, limiting access to ETT & breathing circuit
-ETT is positioned and secured (tape or suture). RAE ETT = common.
-Disconnect tube prior to turning to prevent inadvertent disconnect
-OR table may be turned 90-180 degrees = HOB/airway away from you
-*Remember to add extensions and disconnect circuit when turning bed
-Added length placed prior to draping
-Signs of air leaks (bubbling, air escaping, smell of gas) = more sensitive indicators of leak than mechanical airway monitors
-Arms tucked at side
-Must ensure IV patency, consider 2 IVs for longer procedures

Question 23

What is important to monitor when using a RAE ETT?

Answer 23

Watch for pressure on nares/lips.
-Forehead padding

Question 24

What is a more sensitive indicator of an ETT leak than mechanical airway monitors?

Answer 24

Signs of air leaks (bubbling, air escaping, smell of gas)

Question 25

What nerves do you need to worry about identifying, isolating, and preserving during ENT surgery?

Answer 25

Motor branch of CN7, Recurrent/inferior laryngeal/CN10, CN11

Question 26

What allows for real time ID/functional assessment of vulnerable nerves?

Answer 26

EMG

Question 27

How can you perform Intraoperative neurophysiologic monitoring?

Answer 27

Via Brainstem evoked potentials, electrocochleogram, EMG

Question 28

Describe the "balanced anesthetic technique" utilized with neuromonitoring in ENT surgery?

Answer 28

-TIVA preferred, indifferent to opioids and nitrous oxide -NMBA = only used for intubation -LA are contraindicated (suppressant effect on muscle action)

Question 29

What does the SLN innervate?

Answer 29

mucosa above VC, cricothyroid muscle, tension/elongation of VC

Question 30

What does the RLN innervate?

Answer 30

mucosa below VC, all intrinsic m except cricothyroid, relaxes/abducts/adducts VC

Question 31

What does the Glossopharyngeal Nerve innervate?

Answer 31

epiglottis, tongue, gag reflex

Question 32

What is the motivation for using a different than normal ETT for ENT surgery?

Answer 32

Purpose of various ETT types = reduce cuff pressure on the tracheal wall

Question 33

What is a RAE ETT?

Answer 33

Preformed right-angled ETT prevents ETT kinking, but tip may rest too distal or proximal Requires careful placement check

Question 34

What surgeries would utilize an Oral RAE?

Answer 34

cleft palate, T&A, UPPP, eye, upper face

Question 35

What surgeries would utilize a Nasal RAE?

Answer 35

maxillofacial surgery, cosmetic, oral cavity, malocclusion, mandible

Question 36

In what situations would you avoid nasal intubation?

Answer 36

Avoid nasal intubation in unconscious patient w facial trauma to prevent possible penetration of the brain

Question 37

What is the purpose of using an Armored or Reinforced ETT?

Answer 37

-Embedded coiled wire to produce greater flexibility and memory -Resist kinking & retain original integrity -Useful when acute neck flexion/severe angles of ETT required

Question 38

What is the purpose of using a Laser/Metal-Impregnated ETT?

Answer 38

-reduce risk of airway fire -Cuff filled with methylene blue dyed saline to prevent ignition/early detection -Reflective tape not adequate to prevent fires (bc dry & flammable)

Question 39

What is the purpose of using an LMA?

Answer 39

-Used to facilitate intubation & control the airway -Does not produce tracheal stimulation, Incidence of coughing = lower than ETT, No need for NMB, Conduit for surgical access to the glottis & trachea, Means of isolating the glottis from pharyngeal bleeding

Question 40

What is the purpose of the NIM (Neural Integrity Monitor) ETT?

Answer 40

-Monitors electromyogram (EMG) → must be positioned correctly with markings on ETT between vocal cords -Used for recurrent laryngeal nerve preservation -If nerve is stimulated a response generated at the vocal cords gives an auditory alarm (beep)

Question 41

What is important to know regarding NMBA and the use of a NIM ETT?

Answer 41

-Surgical procedures cannot use NMBA -Sch used for intubation, NDMR used for intubation/positioning -Either let Sch wear off or may have to reverse NDMR

Question 42

What is the purpose of using a Microlaryngoscopy ETT?

Answer 42

-Used for vocal cord & tracheal stenosis surgeries -Longer ETT w smaller diameter (increased resistance to ventilate) -Assist with ventilation to decrease WOB

Question 43

What is the purpose of using Jet Ventilation?

Answer 43

-Used for laryngeal surgery when trachea is not intubated -May be performed manually w hand valve attached to O2 source -Mechanical device allows to adjust rate and O2 concentration

Question 44

What does LASER stand for?

Answer 44

“Light amplification by stimulated emission of radiation”

Question 45

What are the components that make up a Laser?

Answer 45

Energy source + material that excites to emit light

Question 46

What are the most common types of Lasers?

Answer 46

Each laser has specific medical application – CO2 & Nd:YAG most common

Question 47

What are the safety considerations to note when using Laser?

Answer 47

-Must use protective eyewear for patient & staff (lens color specific) -Noxious fumes: particulate from suction plume can lead to pulmonary issues -Staff wear special masks when laser HPV lesions -Small ETT or MLT must be removed during laser (or use special laser ETT) -Lowest concentration O2 possible, FiO2 <30% NO N2O! -Post warning signs of laser use outside operating area -Patient’s eyes protected with appropriate colored glasses/wet gauze -Matte-finish surgical instruments reduce beam reflection/dispersion -Lasers in STANDBY mode when not in use -Inflate cuff w methylene blue saline -Add adjacent tissues shielded w wet gauze -Plume suctioned/evacuated from surgical field -Stop supplemental O2 at least 1 min before & during use of ESU/laser

Question 48

Why do you avoid N2O when using Laser?

Answer 48

Avoid N2O bc it supports combustion