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LONG CASE PRESENTATION

MD Anaesthesia Final Practical Examination

Case: 12-Year-Old Boy with CSOM Planned for Tympanomastoidectomy

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Professor's Opening Note to the Candidate: "When you walk into your final practical, remember - the examiner is not testing whether you memorize drug doses. They want to see a thinking anaesthesiologist. Present systematically. Every clinical finding you mention must lead to an anaesthetic implication. If you say 'the child has CSOM,' the very next thought must be: 'and this affects my anaesthetic plan in the following three ways...' That is how you pass. That is how you practice."

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PART 1: STRUCTURED CASE PRESENTATION

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HOW TO OPEN YOUR PRESENTATION

"Good morning sir/madam. I would like to present a long case of a 12-year-old male child, Master [Name], weighing approximately 32 kg, admitted for elective tympanomastoidectomy under general anaesthesia for chronic suppurative otitis media of the right/left ear."

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SECTION 1: HISTORY

Chief Complaint

• Persistent ear discharge from the right/left ear for [X] years
• Decreased hearing in the affected ear
• Occasional earache and headache

History of Present Illness

• CSOM diagnosed [X] years ago
• Character of discharge: mucopurulent, non-bloody, intermittent/persistent, offensive or non-offensive odour
• Associated symptoms: conductive hearing loss (gradual), tinnitus, occasional vertigo
• No facial palsy (important - rules out cholesteatoma eroding facial canal)
• No headache, neck stiffness, or altered sensorium (rules out intracranial extension - meningitis, brain abscess)
• Conservative treatment tried: topical ear drops, systemic antibiotics - failed to control infection
• Surgery advised: tympanomastoidectomy (combined approach tympanoplasty with cortical mastoidectomy)

Past Medical History

• No known systemic illness (diabetes, asthma, epilepsy, cardiac disease)
• No previous surgeries or anaesthesia (important - no h/o adverse events, malignant hyperthermia, difficult airway)
• No h/o bleeding tendency or clotting disorders

Drug History

• Current medications: topical ciprofloxacin/gentamicin ear drops
• Any systemic antibiotics in recent weeks
• No known drug allergies (NKDA) - always state this explicitly

Family History

• No family h/o anaesthesia-related complications (malignant hyperthermia is autosomal dominant - always ask)
• No family h/o bleeding disorders

Nutritional & Developmental History

• Normal growth and development for age
• Regular school attendance, no cognitive impairment

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"Why is family history of anaesthesia complications relevant here?"

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SECTION 2: REVIEW OF SYSTEMS (RELEVANT)

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SECTION 3: PHYSICAL EXAMINATION

• Well-nourished, well-developed 12-year-old male
• Weight: ~32 kg, Height: ~145 cm
• Afebrile (if febrile - surgery to be deferred; active infection increases anaesthetic risk)
• No pallor, icterus, cyanosis, clubbing, lymphadenopathy, or oedema (PICLE)
• Vitals: HR 88/min, RR 18/min, SpO₂ 99% RA, BP 100/65 mmHg

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"What is the Mallampati classification? Which class does this child belong to?"

• Class I: Soft palate, fauces, uvula, tonsillar pillars visible
• Class II: Soft palate, fauces, uvula visible
• Class III: Soft palate, base of uvula visible
• Class IV: Only hard palate visible

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• Cardiovascular: S1 S2 heard, no murmurs. HR regular.
• Respiratory: Air entry equal bilaterally, no adventitious sounds, no signs of URTI (critical - see below)
• Abdomen: Soft, non-tender
• ENT Examination: Perforated tympanic membrane (central/marginal), mucopurulent discharge, mastoid tenderness on palpation (if present = active mastoiditis)
• Neurological: Cranial nerves intact, no facial palsy, no signs of raised ICP

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"This child has active ear discharge today. Would you proceed with anaesthesia?"

• If the child has FEVER (>38°C), active systemic infection, signs of intracranial complication (meningitis, brain abscess), or a coexisting URTI - surgery should be deferred.
• Active URTI is a significant concern because it increases perioperative respiratory adverse events (PRAE): laryngospasm, bronchospasm, oxygen desaturation. Miller's Anesthesia recommends postponing elective surgery for 4-6 weeks after resolution of URTI symptoms (though this is nuanced by symptom severity).
• Source: Miller's Anesthesia, 10e - URI increases risk of laryngospasm, bronchospasm, breath-holding, atelectasis, and unplanned hospital admission.

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PART 2: PREOPERATIVE ANAESTHESIA MANAGEMENT

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SECTION 4: PREOPERATIVE INVESTIGATIONS

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"Why did you request blood grouping and cross-matching for what seems like a routine ear surgery?"

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SECTION 5: PREOPERATIVE OPTIMISATION

1. Ear discharge: Topical antibiotic ear drops for at least 2-4 weeks pre-operatively to reduce bacterial load (decreases intraoperative contamination)
2. Nutritional status: Optimise nutrition if malnourished (poor wound healing)
3. Haemoglobin: If Hb <10 g/dL - correct anaemia before elective surgery with iron supplementation or blood transfusion
4. Informed consent: From parent/guardian. Explain: general anaesthesia, risks (nausea, vomiting, sore throat, rare risks of aspiration, awareness under anaesthesia, anaphylaxis, difficult airway)
5. Anxiolysis: Reassure child; child life specialist or play therapy pre-operatively
6. Consent for TIVA: Preferred over volatile-based technique (see intraoperative section)

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SECTION 6: PREOPERATIVE FASTING (NPO GUIDELINES)

Professor's Note: Prolonged fasting in children causes hypoglycaemia and dehydration. Always check the last meal time, calculate deficit, and replace intraoperative fluid accordingly.

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"The child is scheduled for 10 AM. When do you allow the last clear fluids?"

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SECTION 7: PREMEDICATION

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"Why is PONV prophylaxis so important in this case?"

1. Female sex would score 1 - here male, so 0
2. Non-smoker - this 12-year-old is a non-smoker = 1 point
3. History of PONV or motion sickness - if present = 1 point
4. Postoperative opioid use - if planned = 1 point
5. Middle ear/inner ear surgery - independent risk factor beyond the Apfel score

• Increase intracranial pressure
• Displace the tympanic membrane graft
• Cause aspiration
• Increase post-operative pain

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PART 3: INTRAOPERATIVE ANAESTHESIA MANAGEMENT

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SECTION 8: OPERATING ROOM SETUP

• Anaesthesia machine checked (O₂, circuit, CO₂ absorber)
• Suction working
• Difficult airway cart available (videolaryngoscope, supraglottic airways, bougie)
• Drugs drawn: propofol, fentanyl, atracurium, atropine, adrenaline, vasopressors
• Paediatric ETT sizes ready: 5.0, 5.5, 6.0 cuffed (for 12-year-old = age/4 + 4 = 7, but actual size based on weight/clinical assessment; cuffed tube preferred)
• Temperature monitoring (paediatrics are prone to hypothermia; maintain warm OR, use warm IV fluids, warming blanket)
• Nerve integrity monitor (NIM) if facial nerve monitoring planned by surgeon

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"What size ETT will you use for this 12-year-old boy?"

• Formula: ETT internal diameter (mm) = (Age/4) + 4 = (12/4) + 4 = 7.0 mm for uncuffed tube
• For cuffed tube: subtract 0.5 = 6.5 mm cuffed
• In practice, always have one size above and one size below (6.0, 6.5, 7.0) ready
• For ear surgery, a south-facing (RAE oral preformed) tube or armoured (reinforced) tube is preferred because the surgical field is the head/neck and the surgeon needs unobstructed access
• Confirm position by auscultation bilaterally and end-tidal CO₂

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SECTION 9: INDUCTION OF ANAESTHESIA

1. Avoids nitrous oxide (mandatory in ear surgery)
2. Propofol-based TIVA significantly reduces PONV compared to volatile agents
3. Provides smoother emergence, less airway reactivity
4. Allows rapid recovery
5. Source: Scott-Brown's Otolaryngology - "TIVA is commonly used. Advantages include improved cardiovascular stability, decreased PONV and a short recovery time."

• Direct laryngoscopy with Macintosh blade size 3
• Insert 6.5 cuffed oral RAE tube (or standard ETT)
• Confirm: bilateral breath sounds, EtCO₂ capnography waveform present
• Inflate cuff to minimum occlusive pressure
• Secure tube firmly with tape
• Eyes taped/padded (corneal abrasion risk with head-turning)

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"Why is succinylcholine avoided in this case?"

1. Risk of malignant hyperthermia - succinylcholine is a known trigger
2. Muscle fasciculations - can increase intraocular pressure, intragastric pressure, and cause myalgias in older children
3. Hyperkalaemia risk in burns, crush injuries, denervation (not applicable here, but principle)
4. Rocuronium with sugammadex reversal is now the preferred alternative for rapid airway control
5. For elective surgery with predicted easy airway, a non-depolarising agent (atracurium, rocuronium) with adequate time for onset is safer and preferred

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SECTION 10: POSITIONING

• Head ring to stabilise head
• 15-degree reverse Trendelenburg (head-up tilt) to:
  • Reduce venous congestion in the head and neck
  • Decrease bleeding in the surgical field
  • Source: Morgan and Mikhail (7e) - "Techniques to minimize blood loss during ear surgery include mild (15°) head elevation"
• Armboard tucked so surgeon can stand freely at the head
• Eyes padded bilaterally - extreme head-turning can cause direct pressure on the dependent eye and corneal abrasion from drapes
• ETT secured on the side AWAY from surgery - double check after final positioning
• Avoid neck flexion/extension - may kink ETT, especially if armoured tube not used

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"What is the danger of extreme head-turning in this position?"

1. Occlusion/kinking of the endotracheal tube - check EtCO₂ and airway pressures after final positioning
2. Venous obstruction - rotation can compress jugular veins on the dependent side, increasing intracranial venous pressure and bleeding at the surgical field
3. Brachial plexus stretch - if shoulder is not adequately padded
4. Vertebral artery compression - in patients with cervical spondylosis (not relevant in this 12-year-old, but important in adults)
5. Pressure on the dependent eye - corneal abrasion or even central retinal artery occlusion

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SECTION 11: MAINTENANCE OF ANAESTHESIA

Option A: TIVA (Preferred)

• No nitrous oxide
• Oxygen in air (FiO₂ 0.3-0.4)
• Maintain BIS (Bispectral Index) 40-60 for adequate depth of anaesthesia
• Short-acting opioids such as remifentanil allow greater control of cardiovascular stability and facilitate controlled/deliberate hypotension

Option B: Volatile-based (if TIVA not available)

• Sevoflurane in oxygen + air (NO N₂O)
• Minimum Alveolar Concentration (MAC) 1.0-1.5 MAC
• Maintain with fentanyl top-ups (1-2 mcg/kg PRN)

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"Explain exactly why nitrous oxide is contraindicated in this case. What happens physiologically?"

1. Displace the tympanic membrane graft - causing surgical failure
2. Rupture the ossicular chain reconstruction
3. Pre-graft placement: even with the ear open, N₂O expands the air, and when the surgeon closes the cavity, a pressure gradient develops
4. If N₂O is stopped AFTER graft placement, the rapid washout of N₂O creates negative middle ear pressure which can also displace the graft
5. Solution: Either avoid N₂O entirely throughout the case (preferred), OR discontinue N₂O at least 15-30 minutes before graft placement and ensure complete washout
6. Additionally, patients with CSOM have obstructed Eustachian tubes - they cannot passively vent middle ear pressure fluctuations, making them particularly vulnerable

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SECTION 12: CONTROLLED/DELIBERATE HYPOTENSION

• Uncontrolled hypertension
• Cerebrovascular disease, carotid stenosis
• Severe anaemia (Hb <8 g/dL)
• Renal insufficiency
• Scott-Brown's notes: "Hypotension should be limited in patients with uncontrolled hypertension, cerebrovascular or ischaemic disease"

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"The surgeon has injected epinephrine 1:50,000 around the ear. You notice sudden hypertension and bradycardia (or tachycardia + tachyarrhythmia). What do you do?"

• Epinephrine 1:50,000 is a higher concentration (compared to 1:200,000) and systemic absorption can cause:
  • Tachycardia and hypertension (beta-1 and alpha-1 effects)
  • Ventricular ectopics or VT (especially with volatile anaesthetics - halothane sensitises most, sevoflurane less so)
• Management:
  1. Alert surgeon to stop further injection
  2. Increase anaesthetic depth (propofol bolus/increase infusion)
  3. If arrhythmia: ensure adequate ventilation (hypocapnia or hypercapnia worsen arrhythmias), correct hypokalaemia
  4. For VT: lidocaine 1 mg/kg IV, esmolol 0.5 mg/kg IV
  5. For refractory hypertension: labetalol, esmolol
  6. Avoid treating bradycardia with atropine if BP is already high - this may worsen hypertension
  7. Document and communicate with surgical team

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SECTION 13: FACIAL NERVE MONITORING

• The facial nerve runs through the mastoid and is at risk of injury during drilling
• Surgeons may request intraoperative facial nerve monitoring (NIM - nerve integrity monitoring)
• If NIM is planned: muscle relaxants must NOT be used in the post-intubation period
• Use a NIM endotracheal tube (electrodes contact the vocal cords to also detect recurrent laryngeal nerve injury in some cases)
• Anaesthesiologist must communicate with the surgeon before case begins about relaxant plan
• Source: Morgan and Mikhail (7e) and Miller's Anesthesia (10e) both emphasise this point

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"The surgeon asks you to give a muscle relaxant mid-surgery because the patient moved. What is your response?"

1. Immediately ask the surgeon - is facial nerve monitoring in use? If yes, NMBs are absolutely contraindicated intraoperatively as they will abolish the EMG signal and make nerve identification impossible.
2. If NIM is NOT in use and patient moved due to inadequate depth - first increase anaesthetic depth (propofol bolus, increase infusion/volatile)
3. If movement persists despite adequate depth - check TOF ratio. If there is residual block, additional relaxant can be given. If TOF ratio is 1.0 (fully recovered), movement suggests light anaesthesia.
4. In TIVA, if the patient is waking up: remifentanil bolus + propofol bolus are first-line
5. Never give a relaxant reflexively without understanding why the patient moved

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SECTION 14: MONITORING

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SECTION 15: FLUID MANAGEMENT

• First 10 kg: 4 mL/kg/hr = 40 mL/hr
• Next 10 kg: 2 mL/kg/hr = 20 mL/hr
• Next 12 kg: 1 mL/kg/hr = 12 mL/hr
• Total maintenance = 72 mL/hr

• If NPO for 8 hours: deficit = 8 × 72 = 576 mL
• Replace: 50% in first hour, 25% in second, 25% in third

• Ear surgery blood loss is typically small (<100-150 mL)
• Calculate MABL = TBV × (Hct_start - Hct_min) / Hct_avg
• TBV in child = 70-80 mL/kg = 2240-2560 mL
• For Hb 12 g/dL (Hct 36%), target minimum Hct 25% (Hb 8 g/dL)
• Replace with crystalloid (3:1) up to MABL; packed red cells if MABL exceeded

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SECTION 16: VENTILATION

• Mode: Volume control or pressure control ventilation
• Tidal volume: 6-8 mL/kg = 190-255 mL
• Rate: 14-18 breaths/min
• EtCO₂ target: 35-40 mmHg (normocapnia)
• Mild hypocapnia (EtCO₂ 32-35 mmHg): May be used to reduce cerebral blood volume and venous ooze
• Avoid hypercapnia - causes vasodilation, increases venous bleeding at surgical site
• PEEP: 3-5 cmH₂O to prevent atelectasis

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PART 4: EMERGENCE AND EXTUBATION

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SECTION 17: EMERGENCE FROM ANAESTHESIA

• Coughing, straining → raises venous pressure → bleeding → graft displacement
• PONV → graft displacement, aspiration
• Pain and agitation → uncontrolled head movement

• Preferred in ear surgery to avoid coughing on the tube
• Pre-requisites: full stomach NOT suspected, no difficult airway, haemodynamically stable, adequate reversal
• Turn patient to lateral position (or semi-lateral) before extubation
• Remove ETT while patient is still in deep plane of anaesthesia (before airway reflexes return)
• Transition to spontaneous ventilation on face mask
• Source: Morgan and Mikhail (7e) - "deep extubation is often utilised" in ear surgery

• Ensure full reversal: neostigmine 50 mcg/kg + glycopyrrolate 10 mcg/kg IV
• Wait for TOF ratio >0.9 (preferred >1.0 with quantitative monitoring)
• Wait for spontaneous breathing, eye opening, purposeful movements
• Give lidocaine 1 mg/kg IV 1-2 min before extubation to blunt cough reflex
• Alternatively: remifentanil infusion continued at low dose (0.01-0.05 mcg/kg/min) during emergence to suppress coughing without causing apnoea

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"You have extubated the child (deep extubation). He suddenly develops stridor and SpO₂ begins to fall. What is your diagnosis and management?"

• Diagnosis: Inspiratory stridor, paradoxical chest movement, SpO₂ falling, no air entry on auscultation
• Immediate management (ladder approach):
  1. Call for help immediately
  2. Jaw thrust + CPAP with 100% O₂ at 20-30 cmH₂O via tight mask - may break incomplete laryngospasm
  3. Larson's manoeuvre: Apply firm pressure in the notch posterior to the mandibular condyle (Larson's point) bilaterally
  4. If SpO₂ < 90% and not responding: Propofol 0.5-1 mg/kg IV (small dose often breaks laryngospasm)
  5. If complete laryngospasm/hypoxia not resolving: Succinylcholine 1-2 mg/kg IV (or 4 mg/kg IM if no IV access) to achieve complete relaxation → bag-mask ventilate → re-intubate
  6. Atropine if bradycardia accompanies (suxamethonium + hypoxia = bradycardia in children)

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PART 5: POSTOPERATIVE ANAESTHESIA MANAGEMENT

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SECTION 18: RECOVERY ROOM (PACU) MANAGEMENT

• Procedure performed, duration, any intraoperative events
• Drugs given (opioids, antiemetics, antibiotics)
• Blood loss and fluids administered
• Type of reversal
• Specific instructions: keep head elevated 30°, avoid vomiting, watch for facial nerve palsy

• SpO₂, HR, BP, RR, EtCO₂ (if still intubated)
• Temperature
• Pain score (Wong-Baker FACES scale or NRS for 12-year-old)
• Level of consciousness (Aldrete score → target ≥9 before discharge)

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SECTION 19: POSTOPERATIVE ANALGESIA

• Source: Scott-Brown's - "Post-operative pain is relatively low and is well managed with paracetamol and NSAIDs except in the mastoidectomy group when opioid analgesia is required."
• Mastoidectomy with significant bone drilling can cause moderate-to-severe pain - anticipate opioid requirements
• Avoid NSAIDS if there is concern about bleeding or renal function

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SECTION 20: PONV MANAGEMENT IN THE POSTOPERATIVE PERIOD

• Non-smoker: +1
• Middle ear surgery: independent risk factor
• Post-op opioid use: +1

• Ondansetron 0.1 mg/kg IV at end of surgery
• Dexamethasone 0.1 mg/kg IV at induction

• Repeat ondansetron 0.1 mg/kg IV (if >6 hours since last dose)
• Metoclopramide 0.15 mg/kg IV (dopamine antagonist - avoid in children <1 year, risk of extrapyramidal effects)
• Promethazine 0.25-0.5 mg/kg IM (antihistamine - sedating, avoid in young children, use cautiously)
• Droperidol 0.01-0.015 mg/kg IV (butyrophenone - effective but watch QT prolongation)

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"The child is vomiting repeatedly in the PACU. You have already given ondansetron. What next?"

1. Rule out surgical causes: haematoma, cerebrospinal fluid leak (rare but can cause vomiting)
2. Rule out pain as a driver of PONV (pain stimulates vomiting)
3. Ensure adequate hydration - IV fluids
4. Switch antiemetic class - if ondansetron (5-HT3 antagonist) has failed, use a different class:
   • Dexamethasone (if not already given maximum dose)
   • Droperidol 0.01 mg/kg IV
   • Scopolamine transdermal patch (limited in paediatrics)
5. TIVA was intended to prevent this - if volatile was used, consider this factor
6. Keep the child in lateral position to reduce aspiration risk
7. Head elevated 30°
8. Inform the surgeon - repeated vomiting risks graft displacement and wound haematoma

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SECTION 21: SPECIFIC POSTOPERATIVE CONCERNS

1. Postoperative Vertigo

• Common after inner ear manipulation
• Reassure patient and parents
• Ambulate slowly and only when stable
• Source: Morgan and Mikhail - "Patients undergoing ear surgery should be carefully assessed for vertigo postoperatively, and their ambulation should be closely monitored to minimise the risk of falling."

2. Facial Nerve Palsy

• Document facial nerve function BEFORE surgery (preoperative baseline)
• Compare postoperatively - if new facial palsy present, inform surgeon immediately
• May be due to surgical trauma, oedema, or infiltration of local anaesthetic
• If immediate and complete: suggests surgical injury → return to OT
• If delayed and partial: post-operative oedema → expectant management, steroids

3. Bleeding and Haematoma

• Monitor wound dressings
• Ear dressing/mastoid pressure bandage assessed every hour
• Blood on pillow or saturated dressing → call surgeon
• Significant haematoma → return to OT for evacuation

4. Hearing Assessment

• Audiometry at 6-8 weeks post-operatively to document hearing improvement

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"What are the indications to return to the operating theatre (re-exploration) in the post-operative period?"

1. Haematoma causing wound expansion, airway compromise, or significant blood loss
2. Facial nerve palsy that is immediate and complete (suggests direct injury - surgical emergency)
3. CSF leak detected (otorrhoea of clear fluid) not resolving
4. Acute hearing loss suggesting ossicular displacement
5. Wound dehiscence with exposure of underlying structures
6. Signs of intracranial complication - new neurological deficit, signs of raised ICP (though rare)

• From anaesthetic standpoint: this is now a semi-urgent/urgent return to OT on a child who has already received anaesthesia - full stomach precautions must be considered if return is within 6-8 hours of last operation (impaired gastric motility, opioid effect, pain/fear slows gastric emptying). RSI (Rapid Sequence Induction) would be warranted.

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PART 6: SPECIAL TOPICS AND ADDITIONAL VIVA QUESTIONS

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"What is the significance of a cholesteatoma in this patient from an anaesthetic standpoint?"

1. Intracranial extension: can erode into posterior fossa → meningitis, brain abscess, sigmoid sinus thrombosis → preoperatively assess for intracranial complications
2. Dural plate erosion: risk of CSF leak or pneumocephalus intraoperatively
3. Facial nerve canal erosion: mandatory facial nerve monitoring
4. Tegmen erosion: risk of meningoencephalocele
5. Sigmoid sinus erosion: catastrophic venous haemorrhage risk
6. CT temporal bone is mandatory to map extent before surgery
7. These complications change the ASA status and surgical risk significantly

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"Briefly outline the anaesthetic considerations specific to a 12-year-old vs an adult for the same surgery."

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"What is your plan if the child refuses IV cannulation and is in tears preoperatively?"

1. EMLA cream (eutectic mixture of lidocaine 2.5% + prilocaine 2.5%) applied under occlusive dressing to dorsum of hand/antecubital fossa 60-90 minutes before induction → numbs the skin
2. Oral midazolam 0.5 mg/kg (max 15 mg) as premedication → excellent anxiolysis and compliance
3. Inhalational induction with sevoflurane (up to 8%) in oxygen via face mask is the traditional paediatric technique - child breathes down to Stage 3 anaesthesia, then IV cannula placed
4. Parental presence at induction - reduces anxiety significantly in children
5. Distraction techniques - tablet/video games in the anaesthetic room
6. Important caveat: For ear surgery specifically, once cannula is in and IV induction done, we transition to TIVA + avoid volatile maintenance to avoid PONV and avoid N₂O

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"Describe your pain assessment tool for this 12-year-old in the PACU."

• NRS (Numerical Rating Scale) 0-10: "Tell me your pain on a scale of 0 to 10." Reliable from age 8+. Most commonly used.
• Wong-Baker FACES Pain Scale: 6 faces from 0 (no pain) to 10 (worst pain). Useful for ages 3-18. Visual, does not require numeracy.
• VAS (Visual Analogue Scale): 10 cm line - reliable from age 8+
• FLACC scale (Face, Legs, Activity, Cry, Consolability): for non-verbal or sedated children; not needed here as child is 12 and verbal
• Target: NRS ≤3 before PACU discharge
• Important: Always use the same scale for serial assessments to track trends reliably

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"Sum up the five key anaesthetic take-home points for this case."

1. No Nitrous Oxide - middle ear surgery with tympanic membrane graft is an absolute contraindication to N₂O due to middle ear pressure dynamics and risk of graft displacement
2. TIVA is preferred - propofol-remifentanil TIVA reduces PONV, provides titratable controlled hypotension, avoids N₂O, and allows rapid, smooth recovery - critical for protecting the surgical repair
3. PONV prophylaxis is mandatory - dual antiemetic prophylaxis (dexamethasone + ondansetron) at induction; PONV threatens graft integrity and risks aspiration in a sedated, head-bandaged child
4. Facial nerve monitoring - confirm with surgeon before using NMBs; if NIM in use, neuromuscular blockade is contraindicated intraoperatively; this must be communicated before the first knife cut
5. Smooth emergence = protected graft - coughing, straining, and bucking on the ETT raises venous pressure and risks bleeding and graft displacement; deep extubation, lidocaine, or low-dose remifentanil at emergence protects the surgical result

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PART 7: CASE SUMMARY TABLE

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Professor's Final Words to the Candidate:

"You have now presented a complete anaesthetic long case. Remember - in the exam, precision and safety thinking matter more than textbook recitation. When the examiner asks 'what would you do?', the answer must always protect your patient first. The moment you anchor your management to patient safety, the examiner knows you are a clinician, not just a student.

One more thing: always close your case presentation by saying - 'I would like to re-examine the child in the anaesthetic room immediately before induction to confirm no interval changes, re-check fasting status, and obtain a final verbal assent from the child.' That statement alone tells the examiner you understand that anaesthesia begins before the first drug is given."

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• Morgan and Mikhail's Clinical Anesthesiology, 7e - Chapter on Ear Surgery, N₂O and ear surgery
• Miller's Anesthesia, 10e - Ear Surgery, Paediatric Anaesthesia
• Scott-Brown's Otorhinolaryngology Head & Neck Surgery - Ear Surgery, TIVA, PONV
• Barash, Cullen, and Stoelting's Clinical Anesthesia, 9e - Paediatric assessment
• Cummings Otolaryngology - Middle ear surgery anaesthesia considerations

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