Nose voice colloquia2-3

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Preface

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Clinical approach to ENT anesthesia involving the Nose Part 2 Ent colloquia

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General principles Surgical and Anesthetic Goals and Results are directly linked through basic knowledge of Anatomy and the Procedure Carefully detailed Plan for a “fluid” perioperative experience Atraumatic intubation Sharing of the airway while allowing optimal surgical exposure Helping to control blood loss and secretions SMOOTH EMERGENCE

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Anesthetic Plan Intelligent Anticipation and Vigilance Patient information Knowledge and expectations of the procedure Spatial arrangement in O.R.

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Atraumatic Intubation

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Traumatic Intubation

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Sharing the Airway while maintaining optimal surgical exposure

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Control of blood loss and secretions Surgeon Anesthesiologist Complexity of the case Well functioning equipment Head positioning

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SMOOTH EMERGENCE Valsalva effect Airway “bucking on the tube” Intolerance to ETT (if used) Blood and/or secretions Nausea Pain

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ANATOMY of the NOSE External Nose- nares and Ala Nasal Cavity (nasal fossae) Nasal Septum Lateral Nasal Wall Nerves Vessels

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Anatomy External nose nasal skeleton nasal bones nasal cartilages blood supply Innervation

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Skeleton of the Nose

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Blood supply of the external Nose

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Innervation of the skin

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NASAL CAVITY

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Nasal Septum

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Lateral Nasal Wall

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General distribution of Nerves to the Lateral Nasal Wall

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The Anterior Ethmoidal and the Sphenopalatine nerves

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Arteries of the Lateral Nasal Wall

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The Septorhinoplasty

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Application of the principles Linking techniques with the surgeons needs Critical points of the surgery Postoperative requirements

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Anesthetic plan 3 variables Patient Case general concerns surgeons skills anesthesiologist skills location of procedure

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Patient Expectations What do I tell them before the surgery?

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Room Preparation

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Workstation

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Specific equipment Oral packing sponges Airway Devices Infusion pump with extension Clear eye tape

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Patient positioning Arms generally tucked Head secured and slightly elevated

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Positioning the Monitors on the Patient Based on Patient positioning Leg to Head? Or Head to Leg? BP Cuff Twitch Monitor?

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Induction: Endotracheal intubation Premedication Patient Positioning Anxiolytics Induction

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Intubation Protect the eyes during Bag-Mask Ventilation with Clear Tape Muscle relaxant The ETT

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Maintenance Securing the ETT and the circuit Preparing for the Epi/Local injection Preparing for the other Critical portions Preparing for a smooth extubation

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Emergence Optimize patient blood pressure Put pt in beach chair/sitting position IV Tylenol infusion Remove Packing Lower cuff pressure Watch patient very carefully for emergence…it happens quickly!

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Exceptions to the Rule Android Morbid Obesity Smokers Teenagers OSA and pulmonary Disorders

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Android Morbid Obesity

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Smokers

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Teenagers

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OSA

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Pulmonary Pathology

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Postoperative concerns

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Conclusion: General principles Surgical and Anesthetic Goals and Results are directly linked through basic knowledge of Anatomy and the Procedure Carefully detailed Plan for a “fluid” perioperative experience Atraumatic intubation Sharing of the airway while allowing optimal surgical exposure Helping to control blood loss and secretions SMOOTH EMERGENCE

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References Hollingshead. Anatomy for surgeons, Vol 1, third edition Nunn,J. Drury, Anesthesia for ENT surgery, 4th edition, Vol 2 Anesthesia in endoscopic sinus surgery, European Archives of Oto-Rhino Laryngology , Vol 260, num.9,481-486,2003

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