Procedures E N T 1 ear examination

Been on vacation last few weeks of 2015 first post in 2016 happy new year

Ear Examination

Objective

To visualize the external auditory canal and the tympanic membrane conditions:

•   Foreign body

•   Wax

•   Furuncle

•   Supportive otitis media

•   Perforation.

Positionwww.surginstruatlas.blogspot.com

Sitting up:

•   Examination with Head mirror.

Supine:

•   Examination with self-illuminating otoscope. No anesthesia required.

Procedure

1.  Pull the auricle upward, backward and laterally.

2.  Introduce aural speculum into the outer part of the auditory canal.

3.  Care should be taken not to introduce the speculum into the bony meatus, as it is very sensitive.

Instruments

•   Head light 

•   Aural speculum 

•   Electrical Otoscope

•   Jobson’s aural probe 

•   Tuning fork 

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Extraction Wisdom tooth 5

Removal of Impacted Wisdom Tooth

Objective

The removal of the third molar tooth, the eruption of which is partially or completely prevented by its contact against the second molar tooth (Fig. 15.17).

Position

Supine, with some reverse Trendelenburg.

Anesthesia

Local or general.

Procedure

1.  Incise gum overlying the tooth.

2.  Cortex of the bone also removed.

3.  Tooth loosened with drill or gouge.

4.  Tooth removed with forceps.

5.  Incision closed with chromic catgut.

Instruments

Dental tray.

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DENTAL OPERATION 4 wisdm tooth percoronitis

Pericoronitis

Objective

To remove pus and infected gum and pus near infected wisdom tooth (Box 15.1).

Box 15.1: Wisdom tooth

A wisdom tooth, usually a lower one, starts to emerge (erupt).

There may not be enough room in the mouth for it to break completely through the gums.

The tooth will push upward on the gums and may only partially expose itself. Some portion of the tooth may remain covered by a flap of gum tissue.

Food particles and bacteria may lodge under the flap, causing a low-grade infection and subsequent swelling.

Position

Supine.

Anesthesia

2% Lidocaine.

Procedure

1.  Identify the pocket remove overlaying flap clean the area thoroughly to remove damaged tissue or pus.

2.  If the area is infected, give oral antibiotics as well. Keep the area clean, which is the best way to prevent recurrences with mouth wash several times a day.

3.  If the condition recurs, remove the unerupted tooth.

Instruments

•   Mouth mirror

•   Explorer

•   2% Lidocaine

•   Syringe for irrigation

•   Saline and hydrogen peroxide

•   Surgical blade.

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DENTAL OPERATION 2 inection jaw

ACUTE INFECTIONS OF THE JAWS

Periapical Abscess

Objective

To drain periapical abscess (acute alveolar abscess).

Position

Supine or sitting.

Anesthesia

General or local.

Procedure

1.  The skin is prepared in an aseptic manner.

2.  The prepared area is draped with sterile towels.

3.  If a local anesthetic is used, a ring block of peripheral skin wheals is made for skin anesthesia. No attempt is made to make a deep injection.

4.  The knife is introduced into the most inferior portion of the fluctuant area.

5.  A small hemostat is introduced into the wound in closed position and then opened in several directions when introduced into the abscess cavity.

6.  A rubber drain is placed in the deepest portion of the wound so that 1 cm remains above the skin surface. It is then sutured in place.

7.  A large dressing is applied.

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DENTAL OPERATIONS 1 Tooth Abcess

Tooth Abscess

Objective

•   To expose and remove infected pulp in case of decayed tooth.

•   To do a root canal treatment procedure to drain the infection out in order to save the tooth and restore it in the near future.

Position

Supine

Anesthesia

2% Lidocaine.

Procedure

1.  An opening is made through the crown of the tooth into the pulp chamber.

2.  The pulp is then removed.

3.  The root canal(s) is cleaned and shaped to a form that can be filled. The root canals are cleaned, enlarged and shaped

4.  Medications may be put in the pulp chamber and root canal(s) to help healing.

5.  A temporary filling will be placed in the crown opening to protect the tooth between dental visits.

6.  The pulp chamber and root canals are filled and sealed.

7.  Next visit the temporary filling is removed and the pulp chamber and root canals are cleaned and filled. In the final step, a gold or porcelain crown is usually placed over the tooth.

Instruments

•   High speed handpiece to open the tooth 

•   Burs

•   Mouth mirror

•   Probe

•   Local anesthesia and syringe

•   Reamers and files to remove the dead pulp tissue

•   Saline and Hydrogen Peroxide to clean the pulp chamber and root canals

•   Cotton rolls

•   Temporary filling material

•   Gutta percha amalgum for the final filling.

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OPHTHALMIC OPERATION 10 Glucoma surgery

Glaucoma Surgery-Trabeculectomy

Objective

In cases of raised intraocular pressure (glaucoma), to bring down the pressure by creating a Channel to take more fluid (aqueous tumor) out of the eye.

Position

Supine.

Anesthesia

General or local (Peribulbar block or retrobulbar block + facial block).

Procedure

1.  Lid speculum.

2.  Superior rectus bridle suture.

3.  Conjunctival flap: cautery of blood vessels.

4.  Dissection of partial thickness scleral flap.

5.  Sclerostomy (block of tissue cut out to create a fistula for fluid drainage).

6.  Peripheral iridectomy.

7.  Anterior chamber reformation.

8.  Scleral flap sutured.

9.  Conjunctival closure.

Instruments

•   Anterior segment set.

•   Cataract set 1.

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OPHTHALMIC OPERATION 8 viterectomy

Vitrectomy

Objective

•   To clean away blood, pus, etc from the vitreous cavity of the eye.

•   As a step in removal of intraocular foreign bodies, complicat­ing retinal detachment operations, etc.

Position

Supine.

Anesthesia

General or local (Peribulbar block or Retrobulbar block + Facial block).

Procedure

1.  Lid sutures passed, clamped.

2.  Conjunctival peritomy.

3.  Rectus muscles isolated.

4.  Infusion port made; infusion started.

5.  2nd entry port made; followed by 3rd port if required.

6.  Vitrectomy performed.

7.  Retina visualized (using contact lens or indirect ophthalmo­scope).

8.  Closure of entry ports and conjunctival closure.

Instruments

•   General Oculoplasty set.

•   Vitrectomy set.

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OPHTHALMIC OPERATIONS 7 Retinal detachment

Retinal Detachment

Objective

In cases of detachment of the retina from the choroid. The detachment is corrected:

•   By cryotherapy

•   By indenting sclera

•   By encircling the sclera.

Position

Supine.

Anesthesia

Local, retrobulbar and facial nerve injection.

Procedure

1.  It may be necessary to divide a rectus muscle to gain access to a retinal break.

2.  By indirect ophthalmoscope the operator visualizes the site of the retinal break.

3.  A cryoprobe is applied until the tissues around the retinal break are treated.

4.  Explant is fixed to the sclera over the site of the retinal break.

5.  To create an indent and achieve mechanical block of retinal breaks.

6.  A silicone strap is passed under the four recti muscles.

7.  The strap is overlapped and secured in the silicone sleeve. Usually done with cryotherapy.

Instruments

•   General ophthalmoplasty set

•   Retinal set

•   Eye speculae (Clark and Lang), 2

•   Fine artery forceps, curved on flat, mosquito, 10

•   Fine dissecting forceps, 2/3 teeth, fixation (St. Martins)

•   Fine dissecting forceps, 1/2 teeth, fixation (Jayles), 2

•   Fine dissecting forceps, non-toothed, fixation (Moorfields), 2

•   Fine scissors, straight, blunt points (Strabismus)

•   Iris scissors, straight, sharp points

•   Bulldog clips, 4

•   Towel clips (Backhaus), 4

•   Cryotherapy, retinal cryoprobe

•   Gass indentor, appropriate explant

•   Fine pen and methylene blue (Optional)

•   4 (1) and 2 (4/0) Synthetic nonabsorbable or black silk on small half-circle round bodied needle for traction sutures

•   1.5 (5/0) Synthetic nonabsorbable on small curved cutting needle

•   0.5 (8/0) Synthetic nonabsorbable or silk on small cutting needle for conjunctiva

•   0.7 (6/0) Synthetic nonabsorbable or silk on small curved cutting needle for marker suture.

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OPHTHALMIC OPERATION 6 Cataract extraction

Cataract Extraction

Objective

In cases of impaired vision due to opaque lens:

•   The removal of an ‘opaque’ crystalline lens.

•   To replace it with an intraocular lens. To restore vision

Position

Supine.

Anesthesia

Local retrobulbar and facial nerve injection.

Procedure

   1.  Insertion of an eye speculum.

   2.  Traction suture is inserted through the belly of the superior rectus muscle.

   3.  The conjunctiva is incised above the limbus.

   4.  A flap of conjunctiva is reflected over the limbus.

   5.  Incisions are made in the limbus.

   6.  Synthetic absorbable stay-stutures are inserted to facilitate closure of the corneal flap.

   7.  The anterior chamber is then irrigated with saline to remove traces of enzymes.

   8.  Extraction of the lens.

   9.  After cataract operations the surgeon may insert a plastic lens implant.

10.  The corneoscleral incision is closed with synthetic absorbable sutures.

11.  The conjunctival incision is closed.

Instruments

•   Anterior segment set

•   Cataract set

•   Diamond knife or razor fragment in holder

•   Eyelid retractors (Desmarre), 2

•   Capsule forceps (Arruga or McPherson)

•   Iris repositor (Bowman)

•   Razor fragment in holder

•   Angled corneal splitter (Tooke)

•   Corneal scissors (Troutmans)

•   Anterior chamber cannula (Ryecroft) with irrigator (Southamptom) for Chymar, Trypsin, Zonulysin (to digest suspensory ligaments)

•   Cryoprobe and cryomachine

•   1 (4) Synthetic nonabsorbable or white silk on small half-circle cutting needle for traction sutures

•   0.5 (8/0) Synthetic nonabsorbable or virgin silk on small curved cutting needle for corneoscleral and conjunctival sutures

•   0.2 (10/0) Synthetic nonabsorbable on small micro point needle for implant fixation

•   Corneal splitter (Tooke)

•   Veetis (Knolle)

•   Fine needle holder (Castroviejo) (Fig. 14.48).

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OPHTHALMIC OPERATION 5 corneal transplant

Transplantation of a corneal graft from stored eye of another human being.

Position

Supine.

Anesthesia

General.

Procedure

1.  The donor eye is held in a suitable stand.

2.  And a graft cut from the cornea using a trephine of appropriate size.

3.  An eye speculum inserted.

4.  Traction sutures of synthetic non-absorbable or white silk passed transversely through the insertions of the superior and inferior rectus muscles.

5.  A fine needle knife is passed into the anterior chamber at the limbus in the upper temporal quadrant.

6.  Sterile air injected into the anterior chamber.

7.  The surface of the graft is flush with the surrounding cornea.

8.  Interrupted or continuous 0. 2 (10/0) synthetic non-absorb­able sutures are inserted to unite the corneal graft to the host.

Instruments

•   Anterior segment set

•   Keratoplasty set

•   Scalpel handle with No. 15 blade

•   Support for donor eye (Tudor Thomas)

•   Scissors, right and left (Troutman)

•   Towel clips (Backhaus), 4

•   1 (4) Synthetic non-absorbable or silk on small half circle, reverse cutting needle for traction sutures of rectus muscles

•   0.7 (7/0) Synthetic non-absorbable or silk on small curved needle with cutting edge on concavity of needle point, for cross-over suture to hold graft in place whilst final sutures are being inserted

•   0.2 (10/0) Synthetic non-absorbable on small curved needle with cutting edge on convexity of needle point for sutures to secure graft in position.

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OPHTHALMIC OPERATION 4 Iredectomy

Iridectomy

Objective

Excision of a segment of iris for:

•   Cysts removal

•   Tumors

•   Glaucoma

•   Iris prolapse.

Position

Supine.

Anesthesia

Local and retrobulbar injection.

Procedure

   1.  Insertion of an eye speculum.

   2.  Traction sutures of synthetic non-absorbable or white silk.

   3.  A conjunctival flap is made to protect the incision.

   4.  Fixation forceps on opposite site of incision.

   5.  Incision at limbus.

   6.  Closed iris forceps inserted.

   7.  Iris grasped.

   8.  Iris withdrawn through opening and cut.

   9.  Return iris.

10.  Incision closed with suture.

Instruments

•   Anterior segment set 1

•   Iris hook

•   Iris repositor (Bowman)

•   Lacrimal cannula with 2 ml syringe for irrigation (balanced sodium chloride solution)

•   Towel clips (Backhaus), 4

•   1 (4) Synthetic non-absorbable or silk on small half circle round bodied needle for traction sutures

•   0.5 (8/0) Synthetic nonabsorbable or silk on small curved cutting needle for conjunctival sutures

•   Eye specula

•   Razor blade fragment holder

•   Micro forceps (Fig. 14.46)

•   Eye scissors (De Wecker) (Fig. 14.47).

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