ENT PROCEDURE 6 ( TONSILECTOMY

Tonsillectomy and Adenoidectomy

Objective

•   Enucleation of the tonsils either by dissection or guillotine so as to remove an infected gland

•   And curetting of the adenoids. 

Position

•   Dissection: Supine, with the head and neck in extension 

•   Guillotine: First supine with the head to one side, and then lateral for adenoidectomy.

Anesthesia

General.

Procedure

1.  A mouth gag is inserted.

2.  The tonsil is held with tonsil holding forceps towards the midline.

3.  Incision made with curved scissor through mucous at the point of joining of anterior pillar and tonsil.

4.  Tonsil freed by blunt dissection.

5.  Bleeding vessel clamped and tied.

6.  Other tonsil also removed in similar manner.

7.  Gag removed after hemostasis.

Adenoidectomy 

Objective

•   Adenoids curetted with adenoid curette 

•   The instruments pressed hard against posterior pharyngeal wall

•   Downward sweep

•   Avoid contact with mucosa of pharynx.

Instruments

Tonsillectomy and Adenoidectomy set.

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ENT Procedure 5 drain pertonsil abcess

Drain Peritonsillar Abscess or Quinsy
Objective
To drain an abscess between the surgical capsule of the tonsil and the superior constrictor muscle and fascia of the adjacent lateral pharyngeal wall.
Position
Sitting, facing the surgeon, or lateral position with the table in slight Trendelenburg.
Anesthesia

Local: 2 cc Lignocaine in the palatal mucosa.
Procedure

1.  Open mouth.

2.  Guide with finger of left hand Parkar knife size 15 to the fluctuant part of visible abscess.

3.  Press point of knife backwards through mucosa into abscess.

4.  Pus gushes out.

5.  Swab and Suck out pus.

6.  Guide sinus forceps into opening.

Instruments

•   Scalpel handle No. 3 with No. 15 blade wrapped with adhesive plaster, tip only exposed

•   Sponge-holding forceps (Rampley) and small sponges or swabs, 5

•   Mouth gag (Mason or Doyen) (Figs 16.15 and 16.16)

•   Angled tongue depressor (Fig. 16.31)

•   Scissors

•   Sinus forceps

•   Pharyngeal spray and 4 percent lignocaine

•   Sterile swab.
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ENT PROCEDURE 4 nasal packing

Preoperative Nasal Packing
Objective

•   Packing of the nasal cavity before operation to provide local anesthesia with lignocaine (Xylocaine) 4 percent.

•   To provide vasoconstriction and hemostasis for the surgeon with 5 to 10 percent cocaine solution with 1 in 10,000 adre­naline added.

•   Too much adrenaline may cause ventricular fibrillation.

•   Packing of nasal cavity is also done for epistaxis to control bleeding.

Position
Supine.
Procedure
1.  The ribbon gauze is impregnated with solution, and one or both nasal cavities are packed using a nasal speculum and dressing forceps.

2.  The ribbon gauze is first passed along the floor of the cavity, and successive layers are built up until it is filled.

3.  The pack is left in place for at least 15 minutes before operation, and is removed gently to avoid trauma of the nasal mucosa.

4.  Spraying the nose with 5 percent cocaine first makes packing with ribbon gauze less unpleasant if the patient is conscious.

Instruments
•   Speculae nasal (Thudichum), different sizes (Fig. 16.28)

•   Dressing forceps, nasal (Tilley or Wilde) (Fig. 16.32)

•   Nasal foreign body hook

•   Roll of 25 mm (1 in) ribbon gauze

•   Lignocaine 4 percent

•   Adrenaline 1 in 10, 000

•   Graduated measure, 15 ml (1/2 oz)

•   Head light, or head mirror and lamp

•   Towel or swab to protect the patient’s lips.

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ENT throat examination 3

Throat Examination

Objective

•   To visualize the palatine tonsil and pillars, posterior pharyn­geal wall, uvula and soft palate.

•   To visualize vallecula, epiglottis, vocal cords, pyriform fossa and other parts of larynx.

Position

Sitting.

Anesthesia

Nil or local.

Procedure

1.  The patient is asked to open his mouth and the anterior 2/3 of the tongue is depressed with this spatula.

2.  At the same time the patient is asked to say aa-aa-ah so that the soft palate moves up allowing a good view of the oropharynx.

3.  The projecting tongue is held with a piece of gauze between the thumb and middle finger of the left hand. The index finger of the doctor elevates the upper jaw.

4.  The mirror is warmed gently to prevent fogging and is tested on the back of the hand for its temperature.

5.  Holding the mirror like a pen it is passed by the side of the uvula into the laryngopharynx.

6.  Avoid touching the posterior pharyngeal wall.

7.  A beam of light is thrown on the mirror and reflected onto the larynx. The patient is asked to say Eeee. . . so that the epiglottis moves up and the phonetic movements of the vocal cords can then be appreciated better.

Instruments

•   Lack’s spatula (Fig. 16.31)

•   Laryngeal mirror

•   Direct laryngoscope

•   Chevalier Jackson laryngoscope with removable slide

•   Fiberoptic laryngoscope.

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Procedures ENT 2 Nose examination

Nose Examination

Objective

To visualize the floor medial and lateral walls of nasal cavity.

The examination of nose comprises of:

•   External examination

•   Anterior rhinoscopy, and

•   Posterior rhinoscopy.

Position

Sitting.

Procedure

It is used to examine the anterior part of nasal cavity (Anterior rhinoscopy):

1.  The thudichum nasal speculum is held in left hand.

2.  The light beam reflected from the head mirror is directed on to the patient’s nostril.

3.  The speculum is closed and gently introduced into the patient’s nostril.

4.  The spring is allowed to open a little to observe the anterior part of:

     •   Floor of nasal cavity

     •   Nasal septum and

     •   Lateral wall of nasal cavity (Middle and inferior turbinates and meati).

Posterior Rhinoscopy

1.  A posterior rhinoscopy mirror and a tongue depressor are needed for this examination.

2.  The mirror is heated gently to avoid fogging and the temperature is tested on the back of the hand before introducing it into the mouth of the patient.

3.  Patient is asked to open his mouth and the tongue is depressed sideways using Lack’s spatula.

4.  The warmed mirror is passed behind the uvula without touching it and is turned upwards and forwards behind palate into the nasopharynx.

5.  The light is focussed onto the mirror and can be reflected from there onto the structures to be visualized.

6.  Care is taken not to touch the posterior pharyngeal wall at any time, as it induces gagging.

7.  The posterior free part of nasal septum and posterior nasal apertures, lower two turbinates and meati are observed for any pathology.

8.  The eustachian tube opening and adenoids are also visualized.

Instruments

•   Thudichum’s nasal speculum 

•   St. Clair Thomson nasal speculum 

•   Posterior rhinoscopy mirror

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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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