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P. Filip et al.

Pulmonary Physiology

Components oftheThoracic Cavity

• Mediastinum

– Boundaries: parietal pleura, sternum/manubrium, vertebrae, diaphragm,

superior aperture of the thorax

– Superior compartment

Between superior aperture of the throat superiorly, manubrium, sternothryoid and sternohyoid muscles anteriorly, upper thoracic vertebrae posteriorly, manubrium to 4th vertebra inferiorly

• Contains thymus, brachiocephalic veins, SVC, aortic arch with three branches, trachea, esophagus, phrenic/vagus nerves, thoracic duct, and lymphatics inferior (anterior, middle, and posterior) compartments

Anterior: posterior to sternum, anterior to pericardium

• Contains fat

Middle: posterior to anterior compartment, anterior to posterior compartment

• Contains pericardium and heart

Posterior: posterior to heart, anterior to thoracic vertebrae

• Contains esophagus with nerve plexus, thoracic aorta, lymphatics, thoracic duct, azygos/hemiazygous veins, and sympathetic trunks

– Brachiocephalic vein

In adults, crosses anterior to the trachea and posterior to the upper half of the manubrium. In children, it crosses over the superior border of the sternum.

– Trachea

Bifurcates at T4–T5 or about 6 cm from the suprasternal notch. In the elderly, trachea can bifurcate at T6. In adults, it is 10–12cm in length and has 16–20 rings, with a diameter of 20 mm × 15mm. Mediastinal fascial layers are a direct continuation of the cervical fascia.

– Esophagus

Four constricting points: cricopharyngeus muscle, aorta crossing, left main stem bronchus crossing, diaphragm

10 Fluids, Hemostasis, Nutrition, andPulmonary Physiology

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• Lungs

– Lung development begins at 3–4 weeks, with true alveoli by 26–28 weeks.

Alveoli development continues after birth.

– Bronchopulmonary segments: Lungs are divided according to bronchial dis-

tribution and not by ssures

Right lung: ten segments

• Right upper lobe (also known as eparterial bronchus)—apical, posterior, anterior

• Middle lobe—superior, medial

• Lower—superior, lateral basal, medial basal, posterior basal, anterior basal

Left lung: eight segments

• Upper—apical-posterior, anterior

• Lingula—lateral, inferior

• Lower—superior, anteromedial basal, lateral basal, posterior basal

– Lymph nodes: divided into two groups per TNM staging

N1—pulmonary nodes N2—mediastinal nodes

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– Arterial supply: Deoxygenated blood, pulmonary arteries; oxygenated, bron-

chial arteries

– Venous return: Deoxygenated blood, azygous-hemiazygous; oxygenated, pul-

monary veins

– Lung: Right lung, three lobes that give 55% of lung volume; left lung, 45% of

lung volume

Chest Diseases

Mediastinal Masses

• Anterior: 50% of mediastinal masses, presents with retrosternal pain, cough, dyspnea, SVC syndrome, chocking sensation

– Thymic tumors (thymomas, carcinoma, carcinoid, lipomas) lymphangioma

(children), goiters, teratoma, lymphoma

• Middle:

– Adenopathy, aortic aneurysm, bronchogenic cyst, pericardial cyst

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• Posterior:

– Neurogenic tumor (schwannoma), esophageal lesion (tumor, diverticula)

P. Filip et al.

Pulmonary

• Obstructive:

– COPD, asthma

• Restrictive

– Sarcoidosis, idiopathic interstitial pneumonias, pneumoconioses, hypersensi-

tivity pneumonitidies, collagen vascular disease, eosinophilic pneumonia – Neuromuscular disorders – Pleural disease, chest wall cavity disorder (i.e., kyphoscoliosis)

• Other:

– Obstructive sleep apnea-hypopnea syndrome—repetitive collapse of upper

airway causing obstructive respiratory events (apnea or hypopnea), associated

with hypoxemia, hypercapnia, and daytime somnolence

Pulmonary Function Test

Provides objective measures of lung function. Can be used to diagnose and manage pulmonary diseases

• Denitions

– Tidal volume (TV) = amount of gas inspired and expired at rest – Residual volume (RV) = volume of gas remaining after maximal expiration,

prevents alveoli collapse – Functional residual capacity (FRC) = amount of gas in lungs after normal

expiration – Total lung capacity (TLC) = total amount of gas in lungs after maximal

inspiration – Forced vital capacity (FVC) = measurement of maximum expiration after

maximum inspiration – Forced expiratory volume in 1 s (FEV1) = volume of the FVC that is expired

within 1 s – Expiratory reserve volume (ERV) = volume of air that can be forcefully

expired after normal expiration – Inspiratory capacity (IC) = volume of air that can be inspired following a

normal expiration

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181

– Forced expiratory ow (FEF) = ow of exhaled air at different points

in the FVC

Done at 25, 50, and 75% of FVC More sensitive in detecting early airway obstruction

– Minute ventilation = TV × RR – Restrictive lung disease—↓ FVC, ↓ RV, and ↓ TLC↑; normal or ↑ FEV – Obstructive lung disease—↑ TLC, ↑ RV, and ↓ FEV

Tests

• Spirometry: most readily available test, measures the rate at which lung changes volume with forced breathing maneuvers.

– Measures forced expiratory volume in 1 s (FEV1), forced vital capac-

ity (FVC).

– FEV1/FVC ratio is normal 75–85%. Decreased ratio signies obstructive pro-

cess; low FEV1 with normal ratio signies restrictive process.

– Flow volume loop is a plot of the inspiratory and expiratory ow against vol-

ume during the forced breathing maneuvers and can help determine the site of airway obstruction (see Fig. 10.1). Intrathoracic obstruction leads to decreased airow particularly during exhalation; during inhalation, the posterior tracheal wall is pulled out by negative intrathoracic pressure, which improves airow. Extrathoracic obstruction leads to decreased airow during inhalation, as the posterior tracheal wall is pulled inward during inhalation. Fixed obstructions do not vary with changes in intrathoracic pressures and thus lead to decreased airow during both exhalation and inhalation.

• Lung volumes—lung volumes of TLC, FRC, and RV are measured.

• Diffusing capacity—diffusing capacity of carbon monoxide (DLCO) used to evaluate obstructive and restrictive lung diseases. Obstructive disease with decreased DLCO is emphysema. Restrictive lung disease with decreased DLCO is interstitial lung disease.

Procedures

• Mediastinoscopy—for diagnostic assessment of medistinal nodes

– Complications of mediastinoscopy—hemorrhage, vocal cord dysfunction,

tracheal injury, pneumothorax

• Bronchoscopy—diagnostic bronchoscopy used for upper airway obstruction, tracheotomy decannulation, persistent cough, hemoptysis, hoarseness, persistent atelectasis, foreign body, lung cancer, neck mass, head and neck neoplasm workup

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P. Filip et al.

Flow

Expiration

Volume

Inspiration

Normal

COPD

Fixed obstruction

Fig. 10.1 Flow loop diagram (from top, left to right). (a) Normal breathing, (b) chronic obstructive pulmonary disease (COPD), (c) intrathoracic obstruction, (d) extrathoracic obstruction, (e) xed obstruction, (f) unilateral obstruction

Extrathoracic obstructionIntrathoracic obstruction

Unilateral obstruction

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183

– Flexible—visualize segmental bronchi and upper lobe bronchi for lung can-

cer staging – Rigid—obtain biopsy, culture, remove foreign body, surgical intervention – Complications of bronchoscopy—hypoxia, respiratory failure, fever, infec-

tion, sore throat, pneumothorax

• Tracheotomy—indicated for patients requiring prolonged mechanical ventilation, aggressive pulmonary toilet, or those with upper airway obstruction

– Complications of tracheotomy

Intraoperative

• Great vessel injury, laryngeal damage, tracheoesophageal partition damage (perforation), pneumothorax, pneumomediastinum

Early postoperative

• Obstruction, displacement, infection, pulmonary edema

Late postoperative

• Tracheal stenosis, granulation tissue, tracheomalacia, tracheoinnominate stula, tracheoesophageal stula, tracheocutaneous stula

• Esophagoscopy—indicated for dysphagia, odynophagia, hoarseness, respiratory distress (i.e., foreign body), diagnosis of lesions, GERD evaluation

– Complications of esophagoscopy—esophageal perforation, trauma to oral

cavity, aspiration, respiratory depression, cardiac instability, pneumothorax, bleeding

Further Reading

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2. Abunnaja S, Cuviello A, Sanchez JA.Enteral and parenteral nutrition in the perioperative period: state of the art. Nutrients. 2013;5(2):608–23.

3. Bordow RA, etal. Manual of clinical problems in pulmonary medicine. 6th ed. Alphen aan den Rijn: Wolters Kluwer; 2005.

4. Brass LF.Thrombin and platelet activation. Chest. 2003;124:18S.

5. Brunicardi F, etal. Schwartz’s manual of surgery. 9th ed. NewYork: McGraw-Hill Education;

2006. p.396.

6. Bumpous JM, Snyderman CH.Nutritional considerations in patients with cancer of the head and neck. In: Myers EN, Suen JY, editors. Cancer of the head and neck. Philadelphia: Saunders;

1996. p.105–16. Chan DK, Parikh SR. Perioperative ketorolac increases post-tonsillectomy hemorrhage in adults but not children. Laryngoscope 124(8):1789–93.

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7. Chen AM, Li BQ, Lau DH, Farwell DG, Luu Q, Stuart K, etal. Evaluating the role of prophylactic gastrostomy tube placement prior to denitive chemoradiotherapy for head and neck cancer. Int J Radiat Oncol Biol Phys. 2010;78(4):1026–32.

8. Cooper DH, et al. The Washington manual of medical therapeutics. 32nd ed. Philadelphia: Lippincott Williams and Wilkins; 2007. p.59–101.

9. Cosmi B, Alatri A, Cattaneo M, etal. Assessment of the risk of bleeding in patients undergoing surgery or invasive procedures: guidelines of the Italian Society for Haemostasis and Thrombosis (SISET). Thromb Res. 2009;124:e6.

10. Detsky AS, Simalley PS, Chang J.Is this patient malnourished? JAMA. 1994;271:54–8.

11. Doherty GM, Albanese CT, Anderson JT, Barbour EF, Barbour JR, Bove EL, etal. Current diagnosis & treatment: surgery. NewYork: McGraw-Hill; 2010.

12. Douketis JD, Spyropoulos AC, Spencer FA, Mayr M, Jaffer AK, Eckman MH, et al. Perioperative management of antithrombotic therapy: antithrombotic therapy and prevention of thrombosis. 9th ed. American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2012;141(2 Suppl):e326S–50S.

13. Elia M.Changing concepts of nutrient requirements in disease: implications for articial nutritional support. Lancet. 1995;345:1279–84.

14. Ernst A. Introduction to bronchoscopy. Cambridge: Cambridge University Press; 2009. p.78–84.

15. Gailani D, Broze GJ Jr. Factor XI activation in a revised model of blood coagulation. Science. 1991;253:909–12.

16. Gann DS, Amaral JF.Fluid and electrolyte management. In: Sabiston DC, editor. Essentials of surgery. Philadelphia: Saunders; 1987. p.29–61.

17. Gee AC, Kiraly L, McCarthy MS, Martindale R.Nutrition support and therapy in patients with head and neck squamous cell carcinomas. Curr Gastroenterol Rep. 2012;14(4):349–55.

18. Giovannini I, Boldrini G, Castagneto M, etal. Respiratory quotient and patterns of substrate utilization in human sepsis and trauma. JPEN J Parenter Enteral Nutr. 1983;7(3):226–30.

19. Goodwin JE, Koluri R. Surgical hemostasis and clotting mechanisms. In: Lee KJ, editor. Essential otolaryngology: head & neck surgery. 10th ed. NewYork: McGraw-Hill Medical;

2012. p.857–69.

20. Hansen JT.Netter’s clinical anatomy. 2nd ed. Philadelphia: Elsevier; 2010. p.73–118.

21. Hyatt RE.Interpretation of pulmonary function tests: a practical guide. 3rd ed. Philadelphia: Lippincott Williams and Wilkins; 2009. p.5–26.

22. Hsueh WD, Hwang PH, Abuzeid WM.Perioperative management of antithrombotic therapy in common otolaryngologic surgical procedures: state of the art review. Otolaryngol Head Neck Surg. 2015;153(4):493–503. https://doi.org/10.1177/0194599815600409.

23. The ICU book. 3rd ed. 2007. p.531–655.

24. Katz DL, Friedman RSC. Nutrition in clinical practice: a comprehensive, evidence-based manual for the practitioner. 2nd ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2008.

25. Kroll MH, Schafer AI.Biochemical mechanisms of platelet activation. Blood. 1989;74:1181.

26. Furie B, Furie BC.Mechanisms of thrombus formation. N Engl J Med. 2008;359:938.

27. Kliegman RM, etal. Nelson textbook of pediatrics. 19th ed. Philadelphia: Saunders; 2011. p.242–5.

28. Laine C, Williams SV, Wilson JF. In the clinic. Preoperative evaluation. Ann Intern Med. 2009;151:ITC1.

29. Lubetsky A, Yonath H, Olchovsky D, Loebstein R, Halkin H, Ezra D.Comparison of oral versus intravenous phytonadione (vitamin K1) in patients with excessive anticoagulation: a prospective randomized controlled study. Arch Intern Med. 2003;163(20):2469–73.

30. Mann KG, Brummel-Ziedins K, Orfeo T, Butenas S.Models of blood coagulation. Blood Cells Mol Dis. 2006;36:108.

31. Matthews TW, Johnson ML, Williams BE, etal. Nutritional status in head and neck cancer patients. J Otoloaryngol. 1995;24:87–91.

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10 Fluids, Hemostasis, Nutrition, andPulmonary Physiology

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32. Morgan A, Mikhail A, Murray A.Clinical anesthesiology. 3rd ed. Philadelphia: Lippincott Williams and Wilkins; 2002. p.365–6.

33. Nicholson JP, Wolmarans MR, Park GR.The role of albumin in critical illness. Br J Anaesth. 2000;85(4):599–610.

34. O’Neill JP, Shaha AR.Nutrition management of patients with malignancies of the head and neck. Surg Clin North Am. 2011;91(3):631–9.

35. Payne RB, Little AJ, Williams RB, Milner JR.Interpretation of serum calcium in patients with abnormal serum proteins. Br Med J. 1973;4(5893):643–6. https://doi.org/10.1136/

bmj.4.5893.643.

36. Pellegrino R, et al. Interpretative strategies for lung function tests. Eur Respir J. 2005;26(5):948–68.

37. Prasad P.Pocket pediatrics: The Massachusetts General Hospital handbook of internal medicine. Philadelphia: Lippincott Williams & Wilkins; 2010. p.6.

38. Sam R, Pearce D, Ives HE.Basic and clinical pharmacology. 13th ed. NewYork: McGrawHill; 2014.

39. Rapaport SI.Preoperative hemostatic evaluation: which tests, if any? Blood. 1983;61:229.

40. Riggin R, Sommer K. 2013 updated systematic review & meta-analysis of 36 randomized controlled trials; no apparent effects of non steroidal anti-inammatory agents on the risk of bleeding after tonsillectomy. Clin Otolaryngol. 2013;38(2):115–29. https://doi.org/10.1111/

coa.12106.

41. Rose BD, etal. Clinical physiology of acid-base and electrolyte disorders. 5th ed. NewYork: McGraw-Hill Education; 2001. p.253–70.

42. Sabatine MS. Pocket medicine: The Massachusetts General Hospital handbook of internal medicine. 3rd ed. Philadelphia: Lippincott Williams & Wilkins; 2008. p.4-1–4-11.

43. Sarhill N, Mahmoud FA, Christie R, Tahir A.Assessment of nutritional status and uid decits in advanced cancer. Am J Hosp Palliat Care. 2003;20(6):465–73.

44. Silver D.What routine preoperative tests for bleeding tendencies? JAMA. 1976;236:2547.

45. Strollo DC, Rosado de Christenson ML, Jett JR.Primary mediastinal tumors. Part 1: tumors of the anterior mediastinum. Chest. 1997;112:511.

46. Strollo DC, Rosado-de-Christenson ML, Jett JR.Primary mediastinal tumors: part II tumors of the middle and posterior mediastinum. Chest. 1997;112:1344.

47. Weinberger SE. Principles of pulmonary medicine. 5th ed. Philadelphia: Elsevier; 2008. p.1–18.

48. You JJ, Singer DE, Howard PA, Lane DA, Eckman MH, Fang MC, et al. Antithrombotic therapy for atrial brillation: antithrombotic therapy and prevention of thrombosis. 9th ed. American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2012;141(2 Suppl):e531S–75S.

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Chapter 11

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Therapeutics: Pharmacology, Chemotherapy, Radiation Oncology

AnniWong, AnthonyDel Signore, andFredY.Lin

Pearls

• Lidocaine

– Low-to-intermediate potency, 45–60min duration – Dosage calculation 1%, 2%, 4% = 10 mg/ml, 20 mg/ml, 40 mg/ml – Dosage max: w/o epinephrine, 5 mg/kg; w/epinephrine, 7 mg/kg

• Types of chemotherapeutic agents

– Alkylating agents: substitution reactions, cross-linking, and strand-breaking

reactions with DNA → inaccurate DNA replication → cell death

– Antimetabolite agents: inhibit critical enzymes involved in nucleic acid syn-

thesis or become incorporated into nucleic acid and produce incorrect codes → inhibition of DNA synthesis during S phase → cell death

A. Wong (*) · A. Del Signore · F. Y. Lin Department of Otolaryngology - Head and Neck Surgery, Icahn School of Medicine at the Mount Sinai Hospital, New York, NY, USA e-mail: anni.wong@mountsinai.org; Anthony.delsignore@mountsinai.org;

fred.lin@mountsinai.org

https://doi.org/10.1007/978-3-031-26048-3_11

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A. Wong et al.

Anesthetics

Local Anesthetics

• See Table11.1 Local anesthetic agents.

• Blocks sodium channels to inhibit action potential; decreases neurotransmission

of nocireceptive signal.

• Order of blockade: sympathetic bers > pain and temperature > touch > motor

function.

• High margin of safety—therapeutic effect: toxic effect.

• Factors in efcacy:

– Lipid solubility: potency and duration – Degree of ionization: penetrance across lipid membranes – Protein binding: duration

• Composed of an aromatic ring and amine group, linked centrally by either an

ester or amide bond.

• Two classes: Mnemonic: “2 I’s” in amides versus “1 I” in esters.

• Toxicity:

– Local: Skin reactivity, cellulitis, ulceration. Watch injection technique and

site of injection.

– Systemic:

Central nervous system: Excitatory to depressive effects. Agitation, tingling, light-headedness, muscle twitching → tonic clonic seizures, unconsciousness, apnea Cardiovascular system: Profound hypotension secondary to systemic vasodilatation and reduced cardiac output, decreased myocardial contractility

– Management:

ABCs approach. Stop procedure → maintain airway and oxygenate. Place IV; administer uids if needed.

Commonly Used Local Blocks

Scalp Block

• Innervated by supratrochlear and supraorbital nerves, zygomaticotemporal and

zygomaticofacial nerves, and the auriculotemporal nerves.

• Entire scalp block requires circumferential inltration from the ears to occiput to

glabella.

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