ROTATION:  Otolaryngology (ENT)  
DURATION: 1 month 
TYPE:  Elective 
FACULTY:  David Bjoraker, MD, Gang Zheng, MD
PREREQUISITES:  Completion of 6 months of clinical anesthesiology rotations 

General Goals: - In addition to all goals listed for General Shands OR Rotations (S1,2,3)

• Learn appropriate preoperative evaluation techniques for patients with known difficult airways including:
  • Patient history
  • Physical Examination
  • Diagnostic data including MRI / CT scan data
    • Including assessment for and implications of chronic airway compression
    • Flow-volume loops and interpretation
• Be familiar with coexisting diseases commonly found in patients undergoing otolaryngologic surgery and their anesthetic implications
• Be familiar with commonly performed pediatric ENT procedures including but not limited to myringotomy and PE tubes, tonsillectomy, and adenoidectomy, necessary preoperative evaluation, and any specialized intraoperative techniques needed
• Be aware of future anesthetic implications of deformative and radical ENT surgery
• Be aware of the advantages and disadvantages of specialized airway techniques (specifically discussed below)

Specific Competencies:  (General Competencies also apply)

PATIENT CARE SKILLS:

• Airway techniques:  Perform and gain competence in the following techniques for airway management (these goals apply to entire continuum of anesthesia training and will not likely be met in one month - the ENT month will have an emphasis on these techniques)
  • Inhalation induction - spontaneous breathing airway management - children and adults
  • Awake intubation of the trachea using any or all of techniques described under intubation techniques below
    • Appropriately decide which patients require awake intubation and which can be equally well or better managed with asleep techniques - be aware of those aspects of patient history and physical examination which will suggest awake or asleep management of the airway
    • Airway analgesic techniques including topicalization, superior laryngeal nerve blockade, glossopharyngeal nerve blockade, transtracheal injection of local anesthetic
    • Airway instrumentation - includes use of Miller and Macintosh blades
      • Flexible fiberoptic techniques
      • Bullard Laryngoscope techniques
      • Wu laryngoscope techniques
      • Use of the LMA in management of the difficult airway

MEDICAL KNOWLEDGE:   (See also General Competencies)

• Difficult Airway Algorithm:  Memorize and master the ASA Difficult Airway Algorithm which is included below and available in complete form with discussion on the Departmental Web Site (click on link above)

• Functional anatomy of the airway - especially supraglottic, glottic and infraglottic structures
  • See web lecture:  Larynx: Form and Function
• Innervation of the pharynx, larynx and trachea
• Flow-volume loops and their use in preoperative evaluation of the airway
  • Indications for flow-volume loop testing
  • Interpretation of flow-volume loops
  • Anesthetic implications of abnormalities found by flow-volume loop testing

INTERPERSONAL AND COMMUNICATION SKILLS, PROFESSIONALISM

• See general competencies section
• Patient management skills related to securing the difficult airway
  • Preoperative counseling and reassurance of the patient with a difficult airway
  • Reassurance and emotional / anxiety management of the patient undergoing awake intubation of the trachea or awake tracheostomy

PRACTICE-BASED LEARNING AND IMPROVEMENT

• See general competencies section
• Learn the process (preoperative and intraoperative) to smoothly intubate the trachea in the awake patient with a difficult airway
• Learn to rapidly intubate the normal and abnormal trachea using alternative intubation techniques described above

SYSTEMS-BASED PRACTICE

• See general competencies section
• Learn about the use of Medi-Alert and Difficult Airway Database systems to assist in future management of the patient with difficult airways.

Evaluation to Determine Goal Achievement 

• You are evaluated every week by all attendings who worked with you (contact-based online computer evaluation system).  These evaluations are reviewed quarterly by the Clinical Competence Committee and continuously by the program director. Your advisor informs you of any problems identified, and serious problems will be discussed with you immediately after they occur. 
• You will complete a Departmental Rotation Evaluation Form. 
• The Residency Program Director will evaluate the results of the In-Training Examination for the American Board of Anesthesiologists (ABA) for areas of departmental weakness. Consistent weaknesses may result in adjustment of the above goals. 

Teaching Resources to Accomplish the Objectives 

• Otolaryngology patients:
  • Pediatric patients including myringotomy / PE tubes, tonsillectomy, adenoidectomy, laryngeal papillomatosis
  • Adult oncologic patients undergoing surgery for head and neck cancers
  • Adult and pediatric patients undergoing otologic and sinus surgery
  • Adult patients undergoing thyroid surgery 
• Text books: 
  • Miller RD, ed. Anesthesia, 4th ed. 
  • Kirby RR, Gravenstein N, eds. Clinical Anesthesia Practice 
  • Barash PG, ed. Clinical Anesthesia, 3rd ed. 
  • Stoelting RK, Miller RD, eds. Basics of Anesthesia
• Online Classic Anesthesia Articles Library 
• Faculty (see attached brief curriculum vitae; full curriculum vitae are available on the departmental computer network): All clinical faculty at the University of Florida participate. The faculty member coordinating this rotation is Dr. David Bjoraker

RETURN TO INDEX FOR GOALS AND OBJECTIVES

Revised 6/2005