7/31/2013

7/31/2013


Answers:
Bjork flaps are contraindicated in pediatric tracheostomies because of higher rates of what complication?
A) Tracheoinnominate fistula
B) Tracheal Stenosis
C) Trach tube displacement
D) Pneumomediastium
E) None of the above

In adults one has the option to use a Bjork flap as it reduces incidence of accidental decannulation and makes reinsertion easier however in children, Bjork flaps are contraindicated due to high rates of tracheal stenosis and persistent tracheocutaneous fistulas.

The Combitube is contraindicated in what group?

The Combitube device is large so it is contraindicated in children or small individuals.

MC Question:
The benefits of percutaneous tracheostomy compared to traditional open tracheostomy include all of the following except.
A) Shorter operative time
B) Less expensive
C) Can be done bedside
D) Easier in obese patients
E) None of the above
F) All of the above

Free Response Question:
What is the difference between tracheotomy and tracheostomy?

Quick Facts:
 Complications of Tracheostomy
-subQ emphysema
-pneumomediastinum
-pneumothorax (caused by progressive pneumomediastinum).
-tracheoesophageal fistula can occur if trach incision is too deep.
-RLN damage can occur during the procedure.
-tube displacement
-tracheal innominate fistula
-tracheal stenosis

 

7/30/2013

7/30/2013
 Answers:

Airway obstructions above the larynx are associated with --- stridor, whereas biphasic stridor is associated with --- obstructions.
A) Inspiratory, supraglottic
B) Expiratory, Tracheal
C)Inspiratory, Tracheal
D)Expiratory, subglottic
E) Inspiratory, subglottic

-Inspiratory Stridor ~ obstruction above larynx
-Expiratory Stridor ~ distal obstruction (i.e. trachea)
-Biphasic stridor ~ subglottic obstruction

Name two advantages and one disadvantage to using a Laryngeal Mask Airway (LMA) in securing an airway.
Advantages: -can be inserted blindly and quickly, -no neck movement required, -95-99% success rate, -easy to learn, -less postop sore throat, cough and laryngeal injury.  
Disadvantage: Risk of LMA is pulmonary aspiration of gastric regurgitation.

MC Question:
Bjork flaps are contraindicated in pediatric tracheostomies because of higher rates of what complication?
A) Tracheoinnominate fistula
B) Tracheal Stenosis
C) Trach tube discplacement
D) Pneumomediastium
E) None of the above

Free Response Question:
The Combitube is contraindicated in what group?

Quick Facts:

 -Percutaneous Trach: increasingly popular. Transcutaneous entry into trachea w/ needle, then guidewire passage into lumen and serial dilation. Often endoscopy is used to confirm entry into tracheal lumen.
-Pros: easy to perform, short operative time, can do at bedside, cheaper, no need to transport patient, lower complication rate.
-Cons: potential more serious complications associated w/ blind entry, difficulty if patient is obese.

 

 
 





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7/29/2013

7/29/2013

Answers:

All of the following are classic signs of tracheoesophageal fistulas except?

A) Hemoptysis 

B) increased tracheal secretions 

C) presence of gastric secretions in airway 

D) recurrent pneumonia 

E) gastric dilation

 

Hemoptysis is a sign of tracheoinnominate fistula, increased tracheal secretions, especially those resembling gastric secretions are a sign of tracheoesophagela fistula. Additionally, this type of fistula may lead to massive gastric dilation as well as recurrent pneumonia secondary to aspiration.

 

Name several ways to prevent tracheoinnominate fistula formation.

Prevention
-limited intubation times (>2wks)
-place trach tube btwn 2-3rd tracheal rings.
-avoid sharp angled tubes.
-proper tracheostomy technique

 

MC Question:
Airway obstructions above the larynx are associated with --- stridor, whereas biphasic stridor is associated with --- obstructions.
A) Inspiratory, supraglottic
B) Expiratory, Tracheal
C)Inspiratory, Tracheal
D)Expiratory, subglottic
E) Inspiratory, subglottic
 

 
 
Free Response Questions:
Name two advantages and one disadvantage to using a Laryngeal Mask Airway (LMA) in securing an airway.




Quick Facts:

-Laryngeal Mask airway (LMA): can be inserted blindly, and quickly, no neck movement required, 95-99% success rate, easy to learn and less postop sore throat, cough and laryngeal injury. Fiberoptic scope can be placed through LMA and tube passed over that for later definitive airway management. Risk of LMA is pulm aspiration of vomit. Contraindications include full stomachs, hiatal hernia, obesity and emergency abdominal surgery.
  -Combitube: double lumen tube w/ tracheal cannula and blocked esophageal end w/ ventilated side holes. Blindly inserted, can ventilate if in trachea or esophagus. Device is large so contraindicated in kids or small people. Be careful if upper airway/esophageal pathology. Also laryngospasm or foreign bodies can impair devices ventilation.

7/26/2013

7/26/2013

Answers:

After undergoing a tracheotomy, a patient has been intubated in the ICU for the past two weeks. A resident rounding on the patient notices that the trach tube cuff is overinflated and that the trach tube is poorly positioned. Suddenly the patient begins to bleed profusely from their mouth and trach site? What is the most likely diagnosis?
A) Aortic Arch Aneurysm 
B) Coagulopathy
C) Tracheoesophageal Fistula
D) Tracheoinnominate Fistula

Tracheoinnominate, a complication of tracheal intubation. Initial management should include overinflatting the tracheal cuff to attempt to stop bleeding as well as manually compressing the artery against the sternum. Then proceed directly to the OR as prognosis is poor.

What are the three types of postintubation stenosis?

Stomal Stenosis
-due to prior trach
-most common cause of benign tracheal stenosis
-once trach removed, granulation tissue forms at opening and scarring creates an A-shaped lumen.
-Lumen must decrease 70-75% for pts to be symptomatic
-dilation often works transiently but ultimately surgery is often needed.
Cuff Stenosis
-due to transmural ischemia below the cricoid.
-requires surgery
Subglottic Stenosis
-due to trauma to endolaryngeal structures distal to vocal cords.
-often caused by improperly placed cricothyroidotomy tube or oversized ETT.

MC Question:

All of the following are classic signs of tracheoesophageal fistulas except?
A) Hemoptysis 
B) increased tracheal secretions 
C) presence of gastric secretions in airway 
D) recurrent pneumonia 
E) gastric dilation

Free Response Questions:
Name several ways to prevent tracheoinnominate fistula formation.

Quick Facts:
Tracheomalacia
-Weakness of the trachea leading to collapse of airway.
-Commonly acquired via trach or ETT intubation.
-Dx w/ endoscopic visualization and cross sectional CT.
Treatment
-Control bronchospasms
-Bipap may be effective.
-Multiple surgical options
-Mesh tracheoplasty appears to be operation of choice currently.

7/25/2013

7/25/2013

Answers:

The blood supply to the superior half of the trachea is primarily --- where the blood supply to the inferior half is primarily---
A) Sup. Thyroid, Bronchial Arteries
B) Inf. Thyroid, Bronchial Arteries 
C) Sup. Thyroid, Inf. Thyroid 
D) Sup. Thyroid, Esophageal Artery 
E) Inf. Thyroid, Esophageal Artery

The main vascular supply of the trachea comes from the Sup. Thyroid artery for the superior half and from the various bronchial arteries (sup. Middle and Inf.) for the inferior half.

At what external landmark does the innominate artery cross over the trachea?

The innominate artery cross over the trachea a the level of the sternal notch.

MC Question:

After undergoing a tracheotomy, a patient has been intubated in the ICU for the past two weeks. A resident rounding on the patient notices that the trach tube cuff is overinflated and that the trach tube is poorly positioned. Suddenly the patient begins to bleed profusely from their mouth and trach site? What is the most likely diagnosis?
A) Aortic Arch Aneurysm 
B) Coagulopathy
C) Tracheoesophageal Fistula
D) Tracheoinnominate Fistula

Free Response Questions:
What are the three types of postintubation stenosis?

Quick Facts:
Tracheoesophageal Fistula
-Nonmalignant TEF commonly caused by cuff over inflation.
-Can also be caused by trauma, granulomatous mediastinal processes, prior trach surg, stents.
-Most TE fistulas are acquired malignant from esophageal cancer.
-poor prognosis
-treat palliatively
Signs/Symptoms
-Increased tracheal secretions, gastric secretions are often seen in airway.
-Pt may have massive dilation of stomach and recurrent PNA.
Treatment
-For nonmalignant attempt to correct surgically w/ debridement and 2 layer closure, interpose strap muscle btwn layers.
-For malignant fistula treat as least invasively as possible.
-Esophageal stenting is common.
-Survival is rarely past 1 year.

7/24/2013

7/24/2013

Answers:

Symptoms of GERD include all of the following except.
A) Halitosis 
B) Ear pain 
C) Cough 
D) Globus 
E) All of the above are symptoms of GERD

What is the main risk factor for esophageal SCC? Adenocarcinoma?

SCC = tobacoo and etoh use as well as chronic ingestion of hot liquids and poor dental hygiene. Adenocarcinoma = GERD

MC Question:

The blood supply to the superior half of the trachea is primarily --- where the blood supply to the inferior half is primarily---
A) Sup. Thyroid, Bronchial Arteries
B) Inf. Thyroid, Bronchial Arteries 
C) Sup. Thyroid, Inf. Thyroid 
D) Sup. Thyroid, Esophageal Artery 
E) Inf. Thyroid, Esophageal Artery

Free Response Questions:
At what external landmark does the innominate artery cross over the trachea?

Quick Facts:
Tracheoinnominate Fistula
-Rare but fatal complication of intubation.
-Due to cuff overinflation or poorly placed tube.
-Dx w/ direct bronchoscopy.
Prevention
-Limited intubation times (>2wks)
-Place trach tube btwn 2-3rd tings.
-Avoid sharp angled tubes.
-Proper tracheostomy technique
Surgical Intervention
-Initial maneuver is to overinflate trach cuff to control bleeding.
-Move directly to OR.
-Can also manually compress artery against sternum.
-Sternotomy is suggested for exposure, ligate artery above and below fistula.
-Remove damaged segment and interpose strap muscle btwn airway and artery.
Prognosis
-25-50% survival rate.

7/23/2013

7/23/2013

Answers:

An esophageal diverticulum that forms as an outpouching through Killians triangle is called?
A) Traction Diverticulum 
B) Epiphrenic 
C) Pharyngoesophageal Diverticulum 
D) Howard's Diverticulum

This is also known as a Zenker's diverticulum. Traction diverticulum are midesophageal and epiphrenic diverticulum are located just above the diaphragm. There is no such thing as a Howard's diverticulum.

The classic appearance of the esophageal mucosa in Barrett esophagus on endoscopy is...

"Salmon Pink" unlike the normal whitish squamous epithelium of a healthy esophagus.

MC Question:

Symptoms of GERD include all of the following except.
A) Halitosis 
B) Ear pain 
C) Cough 
D) Globus 
E) All of the above are symptoms of GERD

Free Response Questions:
What is the main risk factor for esophageal SCC? Adenocarcinoma?

Quick Facts:
The most vascularized tissue in the human body is the carotid body at the bifurcation of the carotid arteries.

7/22/2013

7/22/2013

Answers:

What two muscles make up the upper esophageal sphincter?
A) Cricothyroid and Inf. Constrictor 
B) Cricothyroid and Sup. Constrictor 
C) Cricopharyngeus and Inf. Constrictor 
D) Cricopharyngeus and Sup. Constrictor 
E) Cricopharyngeus and Esophageal Crus

UES = cricopharyngeus and inf constrictor

The superior third of the esophagus is composed of --- muscle whereas the inferior two thirds of the esophagus is composed of --- muscle.

Skeletal; smooth.

MC Question:

An esophageal diverticulum that forms as an outpouching through Killians triangle is called?
A) Traction Diverticulum 
B) Epiphrenic 
C) Pharyngoesophageal Diverticulum 
D) Howard's Diverticulum

Free Response Questions:
The classic appearance of the esophageal mucosa in Barrett esophagus on endoscopy is...

Quick Facts:
Esophageal Cancer
-10K deaths/yr
-Until 1970s mostly SCC in thoracic esophagus of black men.
-Now, in US, adenocarcinoma of distal esophagus make up 50% of cases
-SCC still the most common type worldwide.
-Mostly 60-70s, M>W.
Pathogenesis
-For SCC tobacco and Etoh major factors as well as ingestion of hot liquids and poor hygiene.
-Achalasia, caustic injuries and plummer vinson syndrome associated.
-GERD is most common predisposing factor for adenocarcinoma.
Signs/Symptoms
-Dysphagia, at first just solids, but progresses to liquids.
-Weight loss
-Odynophagia, hoarseness, regurg and aspiration.
Treatment:
-Candidates for esophageal resection if:
-no evidence of tumor spread to other structured.
-no evidence of distant mets
-pt is fit from cardiac/respiratory point of view.
-Two approaches: transhiatal and transthoracic.
-After esophagectomy, continuity is restored using stomach or colon.
-Neoadjuvant therapy has largely failed.
Prognosis
-Stage is most important indicator.
-Overall 5 yr survival is 25-30%, but better if no lymph node mets.

7/19/2013

7/19/2013

Answers:

All of these are common complications of esophageal atresia and TEF repair except.
A) Fistula formation 
B) GERD 
C) Tracheomalacia 
D) Anastomotic Leak 
E) Anastomotic Stricture

GERD, Tracheomalacia, and Anastomotic leak/stricture are all common complication of atresia/TEF repair.

What is the benefit of a thoracoscopic repair for atresia/TEF compared with an open repair?

Complication rates of thoracoscopic approach are much lower.

MC Question:

What two muscles make up the upper esophageal sphincter?
A) Cricothyroid and Inf. Constrictor 
B) Cricothyroid and Sup. Constrictor 
C) Cricopharyngeus and Inf. Constrictor 
D) Cricopharyngeus and Sup. Constrictor 
E) Cricopharyngeus and Esophageal Crus

Free Response Questions:
The superior third of the esophagus is composed of --- muscle whereas the inferior two thirds of the esophagus is composed of --- muscle.

Quick Facts:
Pharyngoesophageal Diverticulum (Zenker)
-From posterior wall of esophagus in killian triangle.
-Killian triangle = cricopharyngeus inf and inf constrictor superiorly.
Signs/Symptoms
-Dysphagia (most common), regurgitation of undigested food, halitosis, hearing gurgling in neck.
-Barium swallow can clearly show position and size of diverticulum
-Manometry can show hypertensive UES and lack of coordinated contractions.
-Treat with excision of diverticulum and myotomy of cricopharyngeal muscle via cervical incision.
-Recently transoral endoscopic management has increased. Wall of diverticulum and cricopharyngeus is divided w/ staples/laser/cautery. Staple is preferred because it seals the cut edges of the wound, but only for short diverticula as stable device cannot advance staple line to end of sac.
-Prognosis is excellent

7/18/2013

7/18/2013

Answers:

The most common variant of esophageal atresai and tracheoesophageal fistula is?
A) esophageal atresia w/ distal TEF
B) esophageal atresia w/o TEF
C) TEF w/o esophageal atresia
D) esophageal atresia w/ proximal and distal TEF
E) esophageal atresia w/ proximal TEF

Over 80% of these disorders involve atresia with a distal TEF.

What does the acronym VACTERL stand for?

Vertebral, Anal, Cardiac, Tracheoesophageal, Renal and Limb. 50% of children born with atresia and TEF will have one of these associated abnormalities.

MC Question:

All of these are common complications of esophageal atresia and TEF repair except.
A) Fistula formation 
B) GERD 
C) Tracheomalacia 
D) Anastomotic Leak 
E) Anastomotic Stricture

Free Response Questions:
What is the benefit of a thoracoscopic repair for atresia/TEF compared with an open repair?

Quick Facts:
Esophageal atresia and TEF are often first diagnosed when it is discovered that a catheter will not pass into the stomach.

7/17/2013

7/17/2013

Answers:

A patient presents to the ED with a stab wound located just lateral to the thyroid cartilage. What classification would this injury fall under?
A) Zone I 
B) Zone II 
C) Zone III 
D) Group II 
E) Group III

-Zone I = sternal notch to cricoid
-Zone II = cricoid to angle of mandible
-Zone III = mandible to skull base

Name three functions of the larynx.

Airway protection, regulation of respiration and phonation.

MC Question:

The most common variant of esophageal atresai and tracheoesophageal fistula is?
A) esophageal atresia w/ distal TEF
B) esophageal atresia w/o TEF
C) TEF w/o esophageal atresia
D) esophageal atresia w/ proximal and distal TEF
E) esophageal atresia w/ proximal TEF

Free Response Questions:
What does the acronym VACTERL stand for?

Quick Facts:
Waterson Classification:  
-Used to predict outcome and determine timing of surgery
-Category A: birth weight >5.5 lbs = prompt surgery
-Category B: BW 4-5.5 or w/ pna and congenital anomaly = short term delay surgery
-Category C: BW < 4 lbs or severe pna and congenital anomaly = staged repair

7/16/2013

7/16/2013

Answers:

With regards to external laryngeal trauma, an injury that causes massive endolaryngeal edema with airway obstruction, mucosal tears that expose cartilage, immobile vocal cords or laryngeal fracture (no more than two) is classified as what?
A) Group II 
B) Zone II 
C)Group III 
D) Group IV 
E) Group V

-Group I = minor endolaryngeal hematoma, no fx; Note that classification for external laryngeal trauma is distinct from penetrating neck trauma (zones I, II, III)
-Group II = endolaryngeal hematoma, compromised airway, nondisplaced fx
-Group III = massive edema, airway obstructed, mucosal tears, immobile cords
-Group IV = group III with more than two fx
-Group V = laryngotracheal separation

Name at least three risk factors for long term damage caused by intubation.

-large diameter ETT
-excessive patient movement
-repeated self extubations
-overinflated ETT cuff
-prolonged intubation.

MC Question:

A patient presents to the ED with a stab wound located just lateral to the thyroid cartilage. What classification would this injury fall under?
A) Zone I 
B) Zone II 
C) Zone III 
D) Group II 
E) Group III

Free Response Questions:
Name three functions of the larynx.

Quick Facts:
Esophageal atresia and tracheoesophageal fistula (TEF) 
-1/3000 live births
-M=F
-Associated w/ prematurity and polyhydramnios
Classification
-Type 1 = esophageal atresia w/ distal TEF (85.4%)
-Type 2 = esophageal atresia w/o TEF ( 7.3%)
-Type 3 = TEF w/o esophageal atresia (2.8%)
-Type 4 = esophageal atresia w/ proximal and distal TEF (2.1%)
-Type 5 esophageal atresia w/ proximal TEF (<1%)

7/15/2013

7/15/2013

Answers:

Clothesline injuries, though rare, classically cause these types of injuries?
A) Cricotracheal separation 
B) Thyrocricoid seperation 
C) RLN injuries 
D) Vagal nerve injuries 
D) A and C 
E) B and D 
F) All of the above

Both cricotracheal separation and b/l RLN injuries are classically caused by clothesline injuries.

Name at least three benefits tracheotomy has over intubation for prolonged airway management.

-decreased dead space
-improve pulmonary toilet
-increased comfort, decreased sedation
-easier weaning
-decreased long term complications

MC Question:

With regards to external laryngeal trauma, an injury that causes massive endolaryngeal edema with airway obstruction, mucosal tears that expose cartilage, immobile vocal cords or laryngeal fracture (no more than two) is classified as what?
A) Group II 
B) Zone II 
C)Group III 
D) Group IV 
E) Group V

Free Response Questions:
Name at least three risk factors for long term damage caused by intubation.

Quick Facts:
Penetrating Neck Trauma
-Classified by zone
-Zone I = sternal notch to cricoid
-Zone II = cricoid to angle of mandible
-Zone III = mandible to skull base
-Injuries above arytenoids often heal on their own, lower injuries often require surgery.
-Image all injuries to zones I (gastrografin) and III (angiography), they are difficult to examine.
-Zone II injuries get surgical exploration without imaging.

7/12/2013

7/12/2013

Answers:

A child with stridor presents to the ED.  A plain film of the neck is obtained which shows a "thumbprint" sign. What is the most likely diagnosis?
A) Laryngotracheobronchitis
B) Supraglottitis
C) Bacterial Tracheitis
D) Foreign Body
E) All of the above
F) None of the above
On plain film croup demonstrates a "steeple" sign, bacterial tracheitis shows a narrowing of the tracheal lumen and epiglottitis/supraglottitis has a "thumbprint" sign.  As epiglottitis has a high mortality rate, you should immediately, but calmly, bring the child to the OR.

What virus is the most common cause of Croup?
 Parainfluenza
 

MC Question:

Clothesline injuries, though rare, classically cause these types of injuries?
A) Cricotracheal separation 
B) Thyrocricoid seperation 
C) RLN injuries 
D) Vagal nerve injuries 
D) A and C 
E) B and D 
F) All of the above

Free Response Questions:

Name at least three benefits tracheotomy has over intubation for prolonged airway management.

Quick Facts:
Intubation Injuries
-Complications include:
-scarring of laryngeal structures
-subglottic/tracheal stenosis
-granulation tissue formation
-vocal fold paralysis/paresis
-4-19% complication rate after prolonged intubation.
-Consider convert to trach after 5-7 days, benefits include:
-decreased dead space
-improve pulmonary toilet
-increase comfort, decreased sedation
-easier weaning
-decreased long term complications
-Risk factors include:
-large diameter ETT
-excessive patient movement
-repeated self extubations
-overinflated ETT cuff
-prolonged intubation.

7/11/2013

7/11/2013

Answers:

What strategy is used to decrease the incidence of subglottic stenosis in intubated children?  
A) Nasotracheal intubations 
B) Using uncuffed tubes 
C) Using smaller tubes 
D) All of the above 
E) None of the above

 When dealing with laryngeal lesions what are the main advantage and disadvantage of using lasers versus microdissection?
Lasers provide better homeostasis however they increase risk of scarring relative to microdissection.

MC Question:

A child with stridor presents to the ED.  A plain film of the neck is obtained which shows a "thumbprint" sign. What is the most likely diagnosis?
A) Laryngotracheobronchitis
B) Supraglottitis
C) Bacterial Tracheitis
D) Foreign Body
E) All of the above
F) None of the above

Free Response Questions:
What virus is the most common cause of Croup?

Quick Facts:
Supraglottitis (epiglottitis)

-In kids 3-6y/o.

-Primarily due to H. flu, incidence down due to vaccine.

-High mortality rate.

-Rapidly progressing, fever, difficulty breathing, severe odynophagia and drooling.

-Inspiratory stridor is a late finding.

-If suspected stop doing everything and take child calmly to OR, have trach kit ready.

-Treat w/ IV Abx (cef usually) and intubation.