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Questions and Answers
In the context of vocal cord polyp removal with laser, which of the following is NOT a potential perioperative complication?
In the context of vocal cord polyp removal with laser, which of the following is NOT a potential perioperative complication?
A crucial safety consideration when utilizing a laser for vocal cord polyp removal is its potential to cause:
A crucial safety consideration when utilizing a laser for vocal cord polyp removal is its potential to cause:
What is the most likely reason why vocal cord polyps typically do not compromise airway patency?
What is the most likely reason why vocal cord polyps typically do not compromise airway patency?
Which of the following best describes the relationship between GERD and vocal cord polyps?
Which of the following best describes the relationship between GERD and vocal cord polyps?
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What is a plausible reason why vocal cord polyps are more frequent in individuals who engage in strenuous voice usage, like singers and orators?
What is a plausible reason why vocal cord polyps are more frequent in individuals who engage in strenuous voice usage, like singers and orators?
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Which of the following is directly suggested by the text as a key element in successful vocal cord polyp treatment?
Which of the following is directly suggested by the text as a key element in successful vocal cord polyp treatment?
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Which of these statements accurately reflects the relationship between vocal cord polyps and nodules?
Which of these statements accurately reflects the relationship between vocal cord polyps and nodules?
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What is the most likely reason why larger vocal cord polyps can result in altered phonation?
What is the most likely reason why larger vocal cord polyps can result in altered phonation?
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What role do anticholinergics play in the anesthetic management of patients undergoing laser removal of vocal cord polyps?
What role do anticholinergics play in the anesthetic management of patients undergoing laser removal of vocal cord polyps?
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Why is minimal energy transfer to surrounding tissues important during laser ablation of vocal cord polyps?
Why is minimal energy transfer to surrounding tissues important during laser ablation of vocal cord polyps?
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How does the presence of vocal cord polyps typically affect respiratory ventilation?
How does the presence of vocal cord polyps typically affect respiratory ventilation?
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What is the purpose of performing laser removal under direct laryngoscopy or microlaryngoscopy?
What is the purpose of performing laser removal under direct laryngoscopy or microlaryngoscopy?
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During laser vocal cord polyp removal, what is the primary justification for using general anesthesia over regional or local anesthesia?
During laser vocal cord polyp removal, what is the primary justification for using general anesthesia over regional or local anesthesia?
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What is a potential advantage of using Heliox during laser vocal cord polyp removal?
What is a potential advantage of using Heliox during laser vocal cord polyp removal?
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Why is the use of longer-acting narcotics discouraged during laser vocal cord polyp removal?
Why is the use of longer-acting narcotics discouraged during laser vocal cord polyp removal?
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What is the primary concern associated with utilizing mask ventilation or reintubation for airway management during intermittent laser applications in vocal polyp removal?
What is the primary concern associated with utilizing mask ventilation or reintubation for airway management during intermittent laser applications in vocal polyp removal?
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Which of the following airway management techniques is associated with the lowest risk of fire during laser vocal cord polyp removal?
Which of the following airway management techniques is associated with the lowest risk of fire during laser vocal cord polyp removal?
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What is the primary purpose of filling the endotracheal tube (ETT) cuff with saline and a dye during laser airway surgery?
What is the primary purpose of filling the endotracheal tube (ETT) cuff with saline and a dye during laser airway surgery?
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Which of the following factors contributes most significantly to the explosive potential of fire ignition during laser airway surgery?
Which of the following factors contributes most significantly to the explosive potential of fire ignition during laser airway surgery?
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In the context of managing an airway fire during laser surgery, which of the following actions should be taken immediately after discontinuing ventilation and oxygen flow?
In the context of managing an airway fire during laser surgery, which of the following actions should be taken immediately after discontinuing ventilation and oxygen flow?
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Based on the provided information, what is the primary reason for choosing sevoflurane as the primary anesthetic agent during laser polyp removal?
Based on the provided information, what is the primary reason for choosing sevoflurane as the primary anesthetic agent during laser polyp removal?
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Which of the following statements accurately reflects the relationship between Reynolds number and the dynamics of fluid flow in a tube?
Which of the following statements accurately reflects the relationship between Reynolds number and the dynamics of fluid flow in a tube?
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What is the primary physiological mechanism by which positive pressure ventilation can help alleviate laryngospasm?
What is the primary physiological mechanism by which positive pressure ventilation can help alleviate laryngospasm?
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Which of the following is NOT a contributing factor to the risk of laryngospasm during the emergence phase of anesthesia after laser vocal cord polyp removal?
Which of the following is NOT a contributing factor to the risk of laryngospasm during the emergence phase of anesthesia after laser vocal cord polyp removal?
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What is the rationale behind using aerosolized racemic epinephrine in the postoperative management of patients who have undergone vocal cord polyp removal?
What is the rationale behind using aerosolized racemic epinephrine in the postoperative management of patients who have undergone vocal cord polyp removal?
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Why is it important to consider the possibility of prolonged muscle paralysis when administering succinylcholine to a patient who has undergone vocal cord polyp removal and received a cholinesterase inhibitor?
Why is it important to consider the possibility of prolonged muscle paralysis when administering succinylcholine to a patient who has undergone vocal cord polyp removal and received a cholinesterase inhibitor?
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Which of the following best describes the potential consequence of delaying treatment for laryngospasm after laser vocal cord polyp removal?
Which of the following best describes the potential consequence of delaying treatment for laryngospasm after laser vocal cord polyp removal?
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Study Notes
Vocal Cord Polyp Removal with Laser
- Vocal cord polyps typically do not obstruct breathing.
- Gastroesophageal reflux disease (GERD) is sometimes connected to polyps.
- A laser is a concentrated beam of light used to remove polyps.
- Potential surgical risks include airway cuts, spasms in the voice box, burns, and eye damage.
- Vocal cord polyps, nodules, and cysts have similar clinical presentations but slight histological differences.
- Vocal cord polyps, nodules, and cysts are usually benign, well-defined, hyperplastic tissue.
- Vocal cord polyps may be a chronic response to airway stress, unlike the acute process associated with vocal cord nodules.
- Smoking and strenuous voice use are risk factors for vocal cord polyps.
- Singers and orators are at increased risk due to vocal cord stress.
- The incidence of polyps is equally distributed between the sexes.
- Larger polyps can affect voice production.
- Laser ablation of vocal cord polyps is most successful when combined with vocal therapy and GERD treatment (if applicable).
- Lasers are a highly focused beams of intense energy that can ablate biological tissues and ignite combustible materials.
- Fire is a risk when lasers are used.
- Burns can occur from the laser beam or from fires ignited by the laser.
- Surgical drapes, sponges, prep solutions, and ETTs are flammable.
- The oxygen-rich environment during anesthesia increases fire risk.
- Eye injuries can occur from the laser beam.
- Laser tissue ablation by-products can contain contagious, mutagenic, and carcinogenic substances.
- Virus transmission, such as human papilloma, can occur in this process.
- Operating room personnel should wear laser masks and the assistant should suction the plume exhaust.
- Special precautions for airway management during laser surgery include: close proximity to ETT and oxygen-enriched ventilation increase risk of fire; low FiO2 levels reduce explosive potential but do not eliminate it entirely. ETT cuffs can be filled with saline and dye, or special "laser tubes" covered in reflective material or adhesive-backed aluminum foil can be used to reduce laser energy ignition.
Surgical Procedure
- Laser removal uses a low-intensity laser to ablate the polyp, minimizing energy transfer to deeper tissues.
- Direct laryngoscopy or microlaryngoscopy guides the laser beam.
- Laser ablation is often near an endotracheal tube (ETT) during mechanical ventilation.
- A rigid bronchoscope with jet ventilation may be used.
- The ETT may be removed during laser use to prevent ignition, then reinserted.
- Mask ventilation or reintubation and ventilation may be done between laser applications to improve vocal cord visualization.
- Manual or high-frequency ventilation via a supraglottic small-bore ETT or high-frequency jet ventilation through a transtracheal catheter can be used.
- A side stream ventilation port on the surgical endoscope may also be used for ventilation.
- Airway management techniques should employ a cuffed ETT to limit the risk of fire from supraphysiologic oxygen concentrations.
- Heliox, a mixture of helium and oxygen, can be used to decrease the potential for combustion.
- A total intravenous anesthetic technique is another option.
Anesthetic Management and Considerations
Preoperative Period
- A standard airway assessment is essential.
- Polyps usually do not cause difficult mask ventilation or intubation, unless large, multiple, or edema is present or other pathology exists.
- Polyps may alter phonation but normally do not affect ventilation.
- Midazolam can reduce preoperative anxiety.
- Anticholinergics (atropine or glycopyrrolate) reduce airway secretions to allow better laser visualization.
Intraoperative Period
- General endotracheal anesthesia is needed for laser vocal cord polyp surgery because it maintains the airway, protects against debris and secretions, isolates the glottic opening, and is required for amnesia, analgesia, and immobility.
- Analgesia attenuates sympathetic discharge from airway stimulation.
- Short-acting or ultra-short-acting narcotics (like remifentanil) are beneficial to blunt airway manipulation stimulation during the procedure.
- Longer-acting narcotics can cause hypoventilation and bradypnea after the procedure.
- Dexmedetomidine can increase anesthetic depth and enhance postoperative analgesia without respiratory depression.
- Immobility is essential to prevent tissue injury or ETT disruption by the endoscope and laser.
- The surgeon may remove the ETT before laser use, followed by mask ventilation or reintubation.
- The fraction of inspired oxygen concentration (FiO2) should be maintained between 21% and 30%.
- Heliox can lower the potential for combustion while improving flow dynamics.
- Sevoflurane is preferred as a volatile anesthetic due to its lack of airway irritation and easy titration. Isoflurane and desflurane cause irritation.
- Total intravenous anesthesia (TIVA) with propofol is appropriate for maintaining anesthesia if intermittent ventilation or significant leaks exist intraoperatively. Interrupting inhaled agents during extubation and laser ablation makes controlling depth difficult; also, TIVA reduces anesthetic gas exposure.
- Neuromuscular blocking agents may be given to maintain immobility. Short- or intermediate-duration agents are best; Sugammadex may be used due to the procedure's short length and risk of residual weakness.
- Laryngeal innervation: innervated by branches of the vagus nerve (superior and recurrent laryngeal nerves). Superior laryngeal nerve (SLN) supplies sensory innervation above and motor to cricothyroid; recurrent laryngeal nerve (RLN) supplies sensory and motor below the cords. Injury to SLN can cause hoarseness and fatigue; injury to RLN causes vocal cord paralysis and potentially airway obstruction, requiring intubation or tracheostomy.
- Visual confirmation of vocal cord movement after polyp removal is important to confirm RLN integrity. The patient is allowed to breathe spontaneously; the method uses direct or fiber-optic visualization in a surgical-plane of anesthesia, avoiding laryngeal spasm and sympathetic hyperreactivity. Injury to the SLN is possible, but unlikely to compromise airway.
Postoperative considerations
- All personnel should be trained in laser safe use.
- Signs warning of laser use and eyewear requirements should be displayed.
- All operating room personnel must wear appropriate laser safety glasses.
- Saline-soaked eye patches, potentially with goggles, should protect the patient’s eyes.
- Preparation to prevent and treat fires and burns is critical.
- A liter bottle of saline or water should be for immediate use to saturate flames.
- The lowest possible oxygen concentration should be used (preferable to use air-oxygen blends to maintain FiO2 between 21% and 30%).
- Use of non-flammable helium as a carrier gas with oxygen can decrease FiO2.
- The laser should be in standby or off mode when not in use and never placed on the patient or surgical drapes.
Fire Treatment
- Immediately discontinue oxygen and ventilation.
- Flood the airway with sterile saline.
- Extubate the patient.
- Verify fire is extinguished.
- Mask ventilate.
- Perform direct laryngoscopy, remove any remnants of the ETT or throat packs.
- Reintubate.
- Perform fiber-optic bronchoscopy to visualize and document injury.
- Corticosteroids and antibiotics are likely needed, along with continued intubation.
Anesthetic Goals for Emergence and Extubation
- Maintain adequate analgesia, decrease airway irritation, and avoid laryngospasm and airway compromise during extubation; deep anesthesia during extubation decreases risk of laryngospasm.
- Lidocaine can attenuate laryngeal reflexes before extubation.
Laryngospasm
- Mechanism: Sensory stimulation of the internal branch of the SLN triggers an afferent reflex arc in the spinal cord. The efferent reflex travels via the external branch of the laryngeal nerve to the cricothyroid muscle, causing contraction (adduction). This muscle tenses the vocal cords. Laryngospasm is a sustained contraction of the cricothyroid muscle.
- Causes: Laser stimulation, irritation, inflammation, and light anesthesia during emergence contribute to laryngospasm risk.
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Treatment:
- Apply positive pressure (10-20 cm H2O) via mask to stretch the cricothyroid muscle, allowing relaxation.
- Manual digital pressure on the pressure point in front of the mastoid process by the angle of the mandible can help attenuate laryngospasm (mechanism unknown).
- Succinylcholine (10-20 mg IV) can relax the muscle if positive pressure fails. Note: succinylcholine given after reversal of neuromuscular blockade will have prolonged action due to pseudocholinesterase inhibition, potentially requiring assisted ventilation.
- Critical Considerations: Delay in treatment allows persistent contraction, potentially making it resistant to positive pressure maneuvers.
Post-Operative Care
- Pain Management: Adequate pain control is paramount; titrated intravenous narcotics alleviate irritation and coughing, reducing risk of laryngospasm.
- Airway Irritation: Postoperative delivery of humidified oxygen, aerosolized racemic epinephrine, and intravenous corticosteroids help manage airway hyperreactivity.
- Monitoring: Stridor indicates potential airway narrowing (edema, vocal cord nerve injury, laryngospasm).
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Description
This quiz covers the essentials of vocal cord polyp removal using laser treatment. Learn about the connection between vocal cord polyps and GERD, as well as the potential surgical risks involved in the procedure. Test your knowledge on this specialized medical topic.
