ENT PROCEDURE 8 stapedectomy

OTOLOGY

Stapedectomy

Objective

•   In cases of loss of hearing due to otosclerosis.

•   To restore hearing by removing the stapes.

Position

Supine with patient’s head turned to the side with the ear to be operated uppermost.

Anesthesia

Local (Premedication given 45 min before surgery).

Procedure

   1.  Preparation of the part.

   2.  Placement of correct size ear speculum.

   3.  Use of operating microscope.

   4.  Injection of local anesthesia.

   5.  Incision in deep meatus at 6-12 o’ clock position in posterior wall 6 mm from tympanic annulus.

   6.  Elevation of tympanomeatal flap including the annulus.

   7.  Bony overhang in posterosuperior part to be curretted to expose the stapes area.

   8.  Making a hole in stapes footplate.

   9.  Division of stapedius tendon.

10.  Disarticulation of incus-stapedial joint.

11.  Enlarging the hole in the footplate.

12.  Measuring the distance between footplate and long process of incus.

13.  Placement of Teflon piston over long process of incus.

14.  Replacement of tympanomeatal flap.

15.  Placement of gel foam/and ear dressing in external canal.

Instruments

Stapes set

•   Circular knife

•   Microscissors

•   Zollner elevators

•   Bone curettes

•   Right angle needles

•   Straight needle stapes microdrill

•   Crocodile ear specula of different sizes

•   Speculum holder measuring rod and grid

•   Suction tube and suction tips.

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ENT PROCEDURE 7 TRACHEOSTOMY

Tracheostomy

Objective

The establishment of an opening into the trachea below the larynx for the insertion of a tube for the purpose of providing an airway in cases of upper respiratory obstruction.

Position

Supine, with a sand bag under the shoulder, blades, neck extended, with the head thrown well back and the chin in the midline.

Anesthesia

•   In cases of emergency, local field block or no anesthesia

•   In elective cases, general anesthesia.

Procedure

   1.  The trachea is fixed between the thumb and middle finger in the midline and an incision is given dividing the skin and platysma.

   2.  In cases of urgency a vertical incision, running from just an inch above the cricoid cartilage to the suprasternal notch.

   3.  In elective cases a transverse incision is given along the skin creases, midway between the cricoid cartilage and the suprasternal notch.

   4.  The strap muscles are retracted laterally to expose the trachea with the overlying isthmus of thyroid.

   5.  The isthmus is freed by dividing the pretracheal fascia in front of cricoid cartilage.

   6.  The freed isthmus can be divided pulled down with the blunt tracheal hook to expose the tracheal rings.

   7.  Now inject a few drops of topical anesthetic into the trachea to minimize the bout of coughing on sudden opening of the trachea.

   8.  The trachea is fixed by means of a sharp hook and second and third tracheal rings are divided in midline.

   9.  The opening so formed is dilated using tracheal dilator.

10.  A correct size tube is selected and introduced into the opening.

Instruments

Tracheostomy set.

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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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