ENT and Eye Anesthesia
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Questions and Answers

What are three potential postoperative complication associated with bilateral neck dissection?

  • Increased airway resistance leading to dyspnea
  • Loss of hypoxic drive due to denervation of carotid elements (correct)
  • Hypotension (correct)
  • Hypocalcemia due to unintentional removal of PTH glands (correct)

    • Which position is typically recommended for a patient undergoing laryngectomy during surgery?

  • Trendelenburg position with legs elevated
  • Supine position with arms tucked and head elevated (correct)
  • Prone position with lateral tilt
  • Supine position with arms extended

    • What is a primary goal during the preoperative assessment for patients undergoing major head and neck surgeries?

  • Evaluating renal function for postoperative recovery
  • Assessing airway patency and nerve functionality (correct)
  • Establishing the patient's alcohol consumption history
  • Identifying previous surgical experiences

    • Which cranial nerve is responsible for the innervation of the lateral rectus muscle?

    <p>Abducens nerve (CN6) (C)</p> Signup and view all the answers

    What is the function of the optic nerve in relation to the eye?

    <p>Transmits light information to the cerebral cortex (C)</p> Signup and view all the answers

    In the context of the oculocardiac reflex, what is the afferent limb?

    <p>Trigeminal nerve (CN5) (A)</p> Signup and view all the answers

    What are the contributing causes to the oculocardiac reflex phenomenon?

    <p>Traction to extraocular muscles and eyeball compression resulting in bradycardia 20% from baseline (B)</p> Signup and view all the answers

    Which cranial nerve is responsible for motor innervation of the orbicularis oculi muscle, allowing for eye closure?

    <p>Facial nerve (CN7) (D)</p> Signup and view all the answers

    What are the actions to take before a surgeon performs a tracheal transection? select 3

    <p>Suction the trachea to minimize aspiration (A), Deflate cuff and pull back to level just above incision (B), Verify placement before ETT is removed (D)</p> Signup and view all the answers

    Which type of laryngectomy involves the removal of both true and false cords along with the epiglottis, cricoid cartilage, and 2-3 tracheal rings?

    <p>Total laryngectomy (D)</p> Signup and view all the answers

    What are the complications associated with tracheostomy placement? select all that apply

    <p>Mediastinal emphysema (A), SQ emphysema (B), pneumothorax (C), airway obstruction (D)</p> Signup and view all the answers

    In the case of a tracheostomy management, what is the correct approach if ventilation is difficult?

    <p>Use the existing stoma for airway management (C)</p> Signup and view all the answers

    Which statement is true regarding the surgical procedure stapedotomy?

    <p>It creates a small hole in the stapes. (B)</p> Signup and view all the answers

    What is important to remember regarding nasal instrumentation with Le Fort fractures?

    <p>Nasal instrumentation is contraindicated for Le Fort 2 and 3 fractures. (C)</p> Signup and view all the answers

    What is the expected outcome of a partial laryngectomy?

    <p>Hoarse voice due to removal of one vocal cord (A)</p> Signup and view all the answers

    What characterizes the NIM tube during intraoperative procedures?

    <p>It allows intraoperative monitoring of laryngeal muscles and requires precision (i.e. Glidescope) for placement (C)</p> Signup and view all the answers

    Which ventilation technique involves high psi (60) and can be performed supraglottic, transtracheal, or via bronchoscope ?

    <p>Jet ventilation (A)</p> Signup and view all the answers

    What are the risks associated with using reinforced/armored tubes?

    <p>Potential occlusion if the patient bites down. Place a bite block! (D)</p> Signup and view all the answers

    What is one disadvantage of using the intermittent apnea technique for ventilation?

    <p>Potential inability to reintubate. (B)</p> Signup and view all the answers

    Which type of airway device is not intended for patients who remain intubated postoperatively? select 2

    <p>NIM tube (A), Reinforced tube (D)</p> Signup and view all the answers

    What is the role of throat packs during a surgical procedure?

    <p>Prevent secretions from reaching the airway. (D)</p> Signup and view all the answers

    What is one advantage of using THRIVE in airway management?

    <p>It improves respiratory mechanics in spontaneously breathing and apneic patients by providing high flow 100% FiO2 (A)</p> Signup and view all the answers

    Which ventilation method uses alternating periods of ventilation and apnea coordinated with surgical work?

    <p>Intermittent apnea (A)</p> Signup and view all the answers

    What is the primary reason to postpone the ear tube procedure or tonsillectomy?

    <p>Active fever and chest symptoms (D)</p> Signup and view all the answers

    What are the key preoperative evaluations for patients undergoing tonsillectomy and adenoidectomy?

    <p>Evaluation for sleep-disordered breathing and URI (A)</p> Signup and view all the answers

    In pediatric patients undergoing tonsillectomy, what is the recommended method for induction?

    <p>Inhalation induction with uncuffed ETT if under 8 years old (D)</p> Signup and view all the answers

    Which is a risk factor for post-tonsillectomy hemorrhage? select 3

    <p>Use of hot cautery (A), Age over 15 years (B), Frequent tonsillitis (D)</p> Signup and view all the answers

    What is the primary concern when recognizing bilateral recurrent laryngeal nerve injury after thyroidectomy?

    <p>Unopposed abduction causing respiratory distress (D)</p> Signup and view all the answers

    What is advised regarding the use of sedatives before an ear tube procedure?

    <p>They should be avoided as they may outlast the procedure (B)</p> Signup and view all the answers

    Why is the 'Rule of 10' significant for cleft palate and cleft lip surgical repair? select 2

    <p>It sets ideal preoperative metrics for better surgical outcomes (A), weight 10kg, Hgb &gt;10, WBC &lt;10k, age &gt;10 weeks (B)</p> Signup and view all the answers

    Which sign is indicative of acute hypocalcemia during parathyroidectomy?

    <p>Laryngospasm (A)</p> Signup and view all the answers

    What should be done during closing of a tonsillectomy to prevent regurgitation of stomach contents?

    <p>Decompress stomach via OGT after securing the airway (B)</p> Signup and view all the answers

    What is the recommended anesthetic management for patients undergoing parathyroidectomy?

    <p>Similar to thyroidectomy (GA) with intraoperative calcium monitoring (A)</p> Signup and view all the answers

    What is the primary method to manage bradycardia during pediatric strabismus repair?

    <p>Administering IV anticholinergic if HR does not recover with cessation of stimulus (C)</p> Signup and view all the answers

    Which factors directly contribute to an increase in intraocular pressure (IOP)? select all that apply

    <p>Hypercarbia and hypoxia (A), Airway obstruction (B), Coughing (C), Trendelenburg position (@)</p> Signup and view all the answers

    What is the normal range for intraocular pressure (IOP) measured in mmHg?

    <p>12-20 mmHg (C)</p> Signup and view all the answers

    Which type of glaucoma medication can cause systemic hypertension?

    <p>Mydriatics - cause direct or indirect effect on dilator muscles of iris (B)</p> Signup and view all the answers

    Which of the following agents is known to increase intraocular pressure shortly after administration?

    <p>Succinylcholine (A)</p> Signup and view all the answers

    What is the primary action of alpha-2 agonists utilized in glaucoma management?

    <p>Decrease aqueous humor production (B)</p> Signup and view all the answers

    What is the purpose of permissive hypotension (MAP 20% below baseline) during surgery, and what additional piece of equipment is required as part of your setup?

    <p>To reduce bleeding and improve surgical visualization; arterial line (A)</p> Signup and view all the answers

    Signup and view all the answers

    Match each specialty ETT with its proper use/description:

    <p>MLT (microlaryngeal tube) = Smaller diameter, longer length RAE = Preformed bend used in dental or facial procedures Laser tube = Pilot balloon filled with saline mixed with methylene blue Armored tube = Embedded coil to be used when severe angles of ETT are required. Use a bite block as well!</p> Signup and view all the answers

    What is the purpose of antisialagogues akak anticholinergics?

    <p>To dry the upper airway and reduce secretions (B)</p> Signup and view all the answers

    What quaternary amine anticholinergic is noted for its longer duration of action and does not cross the blood-brain barrier (BBB)?

    <p>Glycopyrrolate (D)</p> Signup and view all the answers

    What are the benefits of corticosteroids in ENT procedures? (Select all that apply)

    <p>Decreased edema (A), Decreased postoperative nausea and vomiting (PONV) (B), Prolonged analgesia from local anesthesia (LA) (C)</p> Signup and view all the answers

    What is a benefit of LMA (Laryngeal Mask Airway) use during ENT procedures? (Select all that apply)

    <p>Less tracheal stimulation (A), Less coughing on emergence (B), Isolation of glottis from bleeding in pharynx (C)</p> Signup and view all the answers

    How is tracheal gas insufflation performed?

    <p>A smaller catheter is introduced into the nasopharynx and placed above the laryngeal opening. (A)</p> Signup and view all the answers

    What is a disadvantage of jet ventilation?

    <p>It requires a patent upper airway for passive exhalation. (B)</p> Signup and view all the answers

    What are the characteristics of lasers? (Select all that apply)

    <p>Monochromatic - one wavelength (A), Coherent - oscillates in one direction (B), Collimated - exists as a narrow parallel beam (C)</p> Signup and view all the answers

    What characteristic of lasers is determined by the medium used?

    <p>Wavelength - determines function (A)</p> Signup and view all the answers

    What is the relationship between wavelength and water absorption in lasers?

    <p>Directly proportional (A)</p> Signup and view all the answers

    What is the relationship between wavelength and tissue penetration in lasers?

    <p>Indirectly proportional (C)</p> Signup and view all the answers

    Which of the following are examples of mediums used in laser surgery? (Select all that apply)

    <p>CO2 laser (A), Ho:YAG (B), Argon laser (C)</p> Signup and view all the answers

    What type of laser is used in surgeries around the larynx due to its shallow depth of penetration and precision?

    <p>CO2 laser (C)</p> Signup and view all the answers

    What type of laser is commonly used for nasal surgery and tonsillectomies?

    <p>Ho:YAG laser (B)</p> Signup and view all the answers

    What is the minimum prep solutions should dry to prevent fire?

    <p>3 minutes (B)</p> Signup and view all the answers

    What is the triad of fire in the OR?

    <p>Ignition source, fuel, oxidizer (A)</p> Signup and view all the answers

    What adaptations are appropriate for high fire risk procedures? (Select 2)

    <p>Stop supplemental oxygen at least 1 minute before and while using cautery. (A), Use high flow low FiO2. (B)</p> Signup and view all the answers

    Why can N2O be used in BMT procedures?

    <p>Because it is a short procedure and the tubes allow egress of gas (A)</p> Signup and view all the answers

    When does postoperative bleeding typically occur after a tonsillectomy and adenoidectomy (T&A)?

    <p>Within the first 6 hours and then again after 6 days (A)</p> Signup and view all the answers

    What is the most common pediatric airway emergency?

    <p>Post-tonsillectomy hemorrhage - pt is a full stomach (RSI!) (B)</p> Signup and view all the answers

    When should an orogastric tube (OGT) be placed when managing a post-tonsillectomy hemorrhage?

    <p>After intubation when airway is secure (B)</p> Signup and view all the answers

    What does STUBR stand for in the context of sleep disordered breathing assessment?

    <p>Snoring, Trouble Breathing, UnRefreshed after sleep (A)</p> Signup and view all the answers

    What is contraindicated in cleft lip procedures during emergence?

    <p>Oral airway because tip of tongue is sutured to cheek (A)</p> Signup and view all the answers

    Which two nerves associated with breathing lie close to the lateral lobes of the thyroid gland?

    <p>Recurrent Laryngeal Nerve (RLN) and Superior Laryngeal Nerve (SLN) (A)</p> Signup and view all the answers

    What medications should be taken to optimize a patient with hyperthyroidism? (Select all that apply)

    <p>Thyroid medications (A), Beta-blockers (B)</p> Signup and view all the answers

    A patient undergoing a thyroidectomy is hypotensive. What type of medication should be administered?

    <p>Direct acting vasopressor due to sensitivity to catecholamines (A)</p> Signup and view all the answers

    What postoperative complications are associated with thyroidectomies? (Select all that apply)

    <p>Superior laryngeal nerve injury (SLN) (B), Postoperative hematoma (D), Hypocalcemia (A), Recurrent laryngeal nerve injury (RLN) (C)</p> Signup and view all the answers

    What is the expected outcome of a unilateral recurrent laryngeal nerve (RLN) injury?

    <p>Hoarseness without respiratory distress (A)</p> Signup and view all the answers

    What is the expected outcome of an injury to the external branch of the superior laryngeal nerve (SLN)?

    <p>Impaired pitch and voice fatigability (A)</p> Signup and view all the answers

    How would a patient with hypocalcemia present? (Select all that apply)

    <p>Laryngospasm (A), Prolonged QT interval (B), Circumoral numbness (C), Distal extremity numbness (D), Confusion (@), Seizure (@), Chvostek sign (@), Trousseau sign (@)</p> Signup and view all the answers

    What should be included in your preparation for a radical neck dissection? (Select all that apply)

    <p>Type and cross (B), Maintenance of normal BP after skin flap is placed (C), Preoperative antibiotics (D), Second IV because arms will be tucked (A)</p> Signup and view all the answers

    What hormone increases calcium levels?

    <p>Parathyroid hormone (B)</p> Signup and view all the answers

    During a radical neck dissection, a patient exhibits widening of blood pressure and heart rate variation despite minimal blood loss. What is the likely cause?

    <p>Manipulation of the carotid sinus and stellate ganglion (B)</p> Signup and view all the answers

    What is the appropriate way to preoxygenate a patient during tracheostomy if a surgeon is using electrocautery to enter the trachea?

    <p>To FiO2 30% or less (A)</p> Signup and view all the answers

    A patient presents with signs and symptoms of hypocalcemia after undergoing a hemi-mandibulectomy. What is the likely cause?

    <p>Acute hypoparathyroidism due to unintentional removal of parathyroid glands (A)</p> Signup and view all the answers

    What is required for a patient to ventilate independently after a laryngectomy?

    <p>Tracheostomy (B)</p> Signup and view all the answers

    What are the general implications of ear procedures? (Select all that apply)

    <p>Avoid nitrous oxide unless BMT (A), Use muscle relaxants if monitoring (B), Postoperative nausea and vomiting (PONV) are common (C)</p> Signup and view all the answers

    What two nerves that branch off the trigeminal nerve provide tactile sensation to the nose?

    <p>Anterior ethmoidal nerve and sphenopalatine nerve (A)</p> Signup and view all the answers

    What should be anticipated during sinus and nasal procedures? (Select all that apply)

    <p>Need for oral airway due to nasal obstruction (B), Use of muscle relaxants (C), Difficulty masking (A)</p> Signup and view all the answers

    What is the purpose of keeping one eye untapped during sinus surgery?

    <p>To monitor for orbital trauma and nerve damage (A)</p> Signup and view all the answers

    What is the common site of foreign body aspiration?

    <p>Right bronchus (B)</p> Signup and view all the answers

    Your patient aspirated while supine. Where is the most likely site of aspiration?

    <p>Right upper lobe of the lung (A)</p> Signup and view all the answers

    Your patient aspirated while standing. What is the most likely site of aspiration?

    <p>Right lower lobe (C)</p> Signup and view all the answers

    What can make mask ventilation difficult or impossible after cleft palate surgery? select all that apply

    <p>Excessive bleeding (B), Failure to position the head properly (C), Airway obstruction due to surrounding tissue (A), Logan bow apparatus (D)</p> Signup and view all the answers

    What area of the eye contains no blood vessels and is sensitive to pain?

    <p>Cornea (A)</p> Signup and view all the answers

    LR6, SO4, R3 = Lateral rectus is CN 6, superior oblique is CN4, rest are all CN3

    <p>True (A)</p> Signup and view all the answers

    Where are rods and cones located in the eye?

    <p>In the retina (C)</p> Signup and view all the answers

    What nerve is responsible for the dilation and constriction (miosis/mydriasis) of the pupil?

    <p>Oculomotor nerve (B)</p> Signup and view all the answers

    What serves as the afferent branch of the corneal and lacrimation reflex?

    <p>Ophthalmic branch of the trigeminal nerve (B)</p> Signup and view all the answers

    What serves as the efferent limb of the oculocardiac reflex?

    <p>Vagus nerve (B)</p> Signup and view all the answers

    Match the structure to its function:

    <p>Iris and pupil = Regulates light that enters the eye via dilation and constriction Choroid = Middle layer of the eye between the retina and sclera Lens = Transparent structure behind the pupil that refracts incoming light Macula = Yellow spot on the retina at the back of the eye</p> Signup and view all the answers

    Which two cranial nerves work together to change pupil size?

    <p>Optic Nerve (CN II) (A), Oculomotor Nerve (CN III) (B)</p> Signup and view all the answers

    What anesthetic agent should be avoided during surgical procedures involving lasers because it supports combustion?

    <p>Nitrous oxide (B)</p> Signup and view all the answers

    What anesthetic technique is preferred for use during High-Frequency Jet Ventilation (HFJV)?

    <p>TIVA due to environmental contamination from volatiles (A)</p> Signup and view all the answers

    Which anesthetic technique is appropriate for foreign body aspiration below the larynx?

    <p>Inhalation induction maintaining spontaneous ventilation, no PPV, rigid bronchoscopy to retrieve object (A)</p> Signup and view all the answers

    Which anesthetic technique is appropriate for foreign body aspiration above the larynx?

    <p>Laryngoscopy and use of Magill forceps (A)</p> Signup and view all the answers

    What is necessary prior to the insertion of a rigid bronchoscope?

    <p>Good range of motion of the cervical vertebrae (A)</p> Signup and view all the answers

    How is oxygen and inhalation agent delivery achieved during a rigid bronchoscopy?

    <p>Through the side port (@)</p> Signup and view all the answers

    Which of the following endotracheal tubes (ETT) would be most appropriate for a dental procedure?

    <p>Nasal RAE endotracheal tube (B)</p> Signup and view all the answers

    What complication is most common in pediatric strabismus repair?

    <p>Oculocardiac reflex (A)</p> Signup and view all the answers

    What is intraocular pressure determined by?

    <p>The pressure of the aqueous humor (fluid between the lens and cornea) (A)</p> Signup and view all the answers

    Where is aqueous humor produced?

    <p>In the posterior chamber by the ciliary epithelium (B)</p> Signup and view all the answers

    Where does aqueous humor enter and exit in the eye?

    <p>Through the pupil into the anterior chamber and exit via the canal of Schlemm (A)</p> Signup and view all the answers

    What is the Goldman equation as it relates to intraocular pressure (IOP)?

    <p>IOP = (inflow/outflow)/ venous pressure (B)</p> Signup and view all the answers

    What is the normal intraocular pressure (IOP)?

    <p>12-20 mmHg (B)</p> Signup and view all the answers

    What is the effect of succinylcholine on intraocular pressure (IOP)?

    <p>Increases by 5-10 mmHg over 5-10 minutes (A)</p> Signup and view all the answers

    What is the effect of non-depolarizing neuromuscular blocking drugs (NDNMBDs) on intraocular pressure (IOP)? select 2

    <p>No effect (A), Decrease (B)</p> Signup and view all the answers

    Which of the following agents can reduce intraocular pressure (IOP)? select all that apply

    <p>Inhalation agents (A), Propofol (B), Benzodiazepines (C), Opioids (D)</p> Signup and view all the answers

    What movement is controlled by the lateral rectus muscle and which CN is it innervated by?

    <p>Abduction (B), Abducens (D)</p> Signup and view all the answers

    What movement is controlled by the superior oblique muscle and which cranial nerve (CN) innervates it?

    <p>Depression/intorsion, CN IV (B)</p> Signup and view all the answers

    What cranial nerve provides motor innervation to most of the extraocular muscles?

    <p>Oculomotor Nerve (CN III) (A)</p> Signup and view all the answers

    What are the two most common complications after thyroid surgery?

    <p>RLN injury (A), Hypocalcemia (B)</p> Signup and view all the answers

    Study Notes

    ENT Anesthesia Special Considerations

    • Shared airway with surgeon
    • Position patient 90-180 degrees away from anesthesia
    • Ensure endotracheal tube (ETT) secure after repositioning
    • Monitor IV lines carefully
    • Controlled/permissive hypotension, reducing MAP by 20% from baseline
    • Monitor vital signs (UO, MAP, CPP, ABGs, cardiac perfusion)

    Local Anesthetics

    • Cocaine: anesthetic and vasoconstrictive, blocks NE and epi reuptake
    • Lidocaine: rapid-acting, suitable for tracheobronchial tree
    • Benzocaine: short duration, may cause methemoglobinemia (SPO2 near 85%)
    • Bupivacaine: longer duration, intermediate potency
    • Mepivacaine: rapid-acting, moderate potency

    Anticholinergics

    • Atropine/Scopolamine/Glycopyrrolate: decrease secretions and reduce tachycardia; scopolamine more effective for PONV

    Corticosteroids

    • Decrease laryngeal edema and PONV
    • Prolong analgesic effects of local anesthetics

    Vasoactive Drugs

    • Used to minimize blood loss and optimize visualization

    Use of Specialty Glasses and Cover OR Windows

    • Prevent fire by minimizing FiO2 and avoiding nitrous oxide
    • Ensure laser-resistant and well-sealed endotracheal tubes (ETT)
    • Limit laser intensity and duration
    • Utilize saline-soaked pledgets in the airway
    • Allow prep solutions to dry for 3 minutes

    Surgical Fire

    • Common fuels: hair, tissue, alcohol preps, dressings, drapes
    • Assess for risk factors: surgery above xiphoid, open oxygen source, accessible ignition source
    • Classify fire risk levels: 1 (low), 2 (low with potential to escalate), 3 (high)

    Insufflation (Tracheal Gas Insufflation)

    • Used in laryngeal procedures
    • Smaller catheter through nasopharynx placed above laryngeal opening
    • Can use side-arm channel of laryngoscope/bronchoscope for ventilation
    • Delivers 60 PSI inhalation, passive exhalation
    • Avoid air trapping, barotrauma, and hypercarbia

    Airway Management - Ventilation

    • Different types (jet)
    • Use in spontaneously breathing or apneic pts

    BMT (Bilateral Myringotomy Tubes)

    • Performed for chronic otitis media, frequent URI
    • Ultrashort procedure
    • No IV, always have airway equipment available

    Thyroid Procedures

    • Preop eval for airway and thyroid hormone levels
    • Monitor thyroid meds and beta-blockers
    • Supine position, HOB elevated 30 degrees, neck extended
    • Monitor for hypocalcemia (can be an emergency)

    Tracheostomy

    • Preoxygenate unless electrocautery is used
    • Deflate ETT before tracheal transection
    • Ensure proper placement and ventilation

    Laryngectomy

    • Removal of hyoid bone, entire larynx, cricoid cartilage, 2-3 tracheal rings
    • Requires tracheostomy for post-operative ventilation

    Procedures that can be performed due to HPV or need for nerve monitoring

    • Lengthy procedure with risk of blood loss
    • Supine position, arms tucked, HOB elevated
    • Moderate controlled hypotension
    • Minimize vasoconstrictors/dilators
    • Monitor for hypocalcemia

    Ear Procedures - General Notes

    • Stapedotomy
    • Tympanoplasty
    • Mastoidectomy
    • Cochlear implant

    Facial Trauma - Le Fort Classifications

    • No nasal instrumentation for Le Fort 2 and 3 procedures
    • Planning for planned intermaxillary fixation or tracheostomy needed

    Sinus & Nasal Procedures

    • Assess for difficulty with mask ventilation
    • Reinforced/RAE ETT
    • Ensure adequate muscle relaxation due to proximity to brain and eye

    Miscellaneous Procedures

    • Preparing for emergency cricothyroidotomy/tracheostomy

    • Preparing for ophthalmic surgeries

    • Ophthalmic structures and innervations

    • Ocular diseases.

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