Otorhinolaryngological Surgery

Otorhinolaryngological Surgery

Otorhinolaryngological Surgery ENT SURGERY Purpose Ear: improve, restore, preserve hearing Nose: restore or improve breathing/ventilation, ensure drainage of the sinuses, control epistaxis Throat: prevent infection, remove a tumor/ mass, perform life-saving procedures

Otorhinolaryngological Surgery Terms Ear Nose A &P

Throat Pathology Endoscopy& Meds Anesthesia Triple endoscopy Positioning, Prep, & Draping Thyroid &Equipment, Supplies, Parathyroids & Instrumentation Tracheotomy & Complications Considerations

The Ear TERMINOLOGY of the EAR Auditory- related to sense of hearing Auditory acuity- sharpness/acuity of sense of hearing Aural related to the ear Conduction transmission of sound waves through air or bone (conduction media) Conductive loss hearing loss related to external or middle ear defect, disease, infection, trauma (can be restored by surgery) Decibel unit used for measuring sound and degree of hearing loss Mastoiditis inflammation in mastoid process Menieres Disease or Syndrome- disorder of inner ears labyrinth (sx: deafness, tinnitus, dizziness, feeling of ear pressure or fullness)

Ossicle referring to one of the following small ear bones: malleus, incus, stapes Terminology of the Ear Continued

Otitis media acute or chronic inflammation of the middle ear Oto related to the ear Otology related to the ear Otosclerosis formation of spongy bone around the oval window that causes immobility of the stapes resulting in deafness PE Tubes (pressure equalization) drainage tubes placed in the eardrum or tympanic membrane allowing drainage of fluid in the middle ear preventing fluid build up that leads to infection Sensorineural loss defect in the inner ear from nerve tissue damage that causes hearing loss (surgery does not help) Tinnitis a subjective symptom of ringing in the ear Vertigo sensation of dizziness

Anatomy of the Ear 1. 2. Outer Ear Auricle or pinna Auditory meatus extends to the tympanic membrane Lined with fine hairs Ceruminous glands secrete cerumen

Function to collect sound and direct it down a hole in the temporal bone Anatomy of the Ear 3. Tympanic Membrane Eardrum Separates outer ear from middle ear Normally pearly grey Anatomy of the Ear 4.

Middle Ear Tympanic cavity Eustasian tube/canal equalizes pressure Auditory ossicles: lateral to medial (from tympanic membrane in): Malleus (hammer) Incus (anvil) Stapes (stirrup) Anatomy of the Ear

5. Inner Ear (labyrinth) Bony Membranous Are complex canals and chambers called the semi-circular canals Equilibrium (Vestibular Apparatus) Hearing (Organs of Corti in the Cochlea)

Physiology of Hearing Hear a sound>hits auricle>external auditory canal>tympanic membrane (vibration occurs) >malleous connected to tympanic membrane and therefore moves>incus moves>stapes moves>in and out of oval window>pushes on perilymph fluid in bony canal of vestibule>pushes on vestibular membrane and pushes endolymph fluid in the hollow of the chambers>which pushes against a membrane of the organ of corti housed in the cochlea to move>this stimulates axons which become the cochlear branch of vestibulo-cochlear

nerve>ending in the auditory area of cerebrum that interprets sounds Equilibrium Semicircular canals (3 per ear) Hollow filled with fluid endo-lymph Axons form vestibular portion of vestibulocochlear nerve Fluid when turn or spin stimulates dendrites and tell body you are moving in a certain direction Detect 3 planes of movement Primarily interpreted in cerebellum

Cranial Nerve VIII Vestibulo-cochlear (VIII) Vestibular portion balance Cochlear portion hearing Pathology

Hearing Loss Three main types: Conduction type (interference) Sensorineural (nerve deathcochlea)) Mixed-Type (conduction and nerve)-can only Other types: Congenital-rubella or toxic drug

exposure in utero Neonatalprematurity, trauma, Rh incompatibility Central-acoustic portion of cerebral

Outer Ear Obstruction Exostoses-outgrowths in outer ear canal Polyps Infection Abscess Pathology Middle Earmembrane Tympanic Trauma Perforation Perforation

Rupture Fluid accumulation Otitis media Otosclerosis-overgrowth of stapes (stapedectomy) Pathology Inner Ear Mastoid Menieres Mastoiditissyndrome-endolymphatic fluid absorption failure-can tx surgically with a

Cholesteatomashunt medical treated is unseccuessful benignif tumor usually result of ruptured eardrum that has not healed properly, can erode into mastoid one Diagnostic Testing Audiometry - measures hearing Otoscope scope used to view external and middle ear

CT scan MRI Tympanogram contrast middle ear through Eustachian (auditory) tube Electronystagmogram (ENG) - assesses extra-occular muscles (nystgmus=involuntary back and forth movement of eyeballs) caused by lesions of labyrinth or vestibular branch of VIII Anesthesia General: Inhalation (LMA) Intubation

Medications Local anesthetics (with or without epinephrine) Gelfoam Bone wax Antibiotics (topical or systemic) Anti-inflammatory agents Position Bed reversed to allow operative team to sit with feet under bed

Supine Headrest with operative ear up Arms tucked Pillow under the knees Prep Small area may be shaved Hairline to shoulders and from midline of face to behind operative ear If a solution is used prevent pooling in the ear or contact with the eyes

Draping Head wrap Towels Body drape ENT drape Supplies, Equipment, Instrumentation

Buck (ear) cottonoid Moistened currette sponges Burrs Iris

scissors Micro Ear speculum Rotating drill Microscope Applicator Argon Laser Bayonet forceps Cautery (alligator) forceps Hartman Speculum Sexton

earHolder knife Nerve stimulator Frazier suction Baron suction tip Elevator Kerrison ronguer Chisel Mallet The Nose Terminology of the Nose

Paranasal sinusesAnosmia-loss of smell air cavities in the bone around the nasal cavity lined with mucous membranes (frontal, ethmoid, sphenoid, Apnea-not breathing maxillary) Epistaxis-nose bleed Parosmia-disorder affectingtosmell Hyperosmia-oversensitive Rhinitis-inflammation

of the nasal mucosa odors Rhino-related to the nose Nares (Naris)-nostrils Sinus-cavity bone Nasal-relatedintoa the nose Nasal Turbinates-four bony projections or ridges in the nasal cavity (supreme, superior, middle, inferior) Olfactory- related to smell

Anatomy of the Nose External Nose - tip to face Internal Nose - turbinates (scroll-like bone in nasal cavity) divided by septum Paranasal Sinuses cavities within respectively named bones Function of Nose Olfaction Warming and filtration of inspired air

Physiology of Smell Receptors in upper or superior nasal cavity Bipolar neurons (receptors) pick up a different chemoreceptor Are about 50 receptors Axons form olfactory nerve (I) These go into cribiform plate (sieve-like bone in

skull) End in olfactory bulbs under frontal lobe of cerebrum Cranial Nerve I Olfactory (I) smell (olfaction) Pathology Rhinitis Sinusitis Nasal polyps Hypertrophied turbinates

Deviated septum Septal perforation Epistaxis Diagnostic Testing Direct Vision Mirror Examination Radiographic exams Anesthesia General Inhalation

Intubation Local with IV sedation Medications

Topical anesthetic (cocaine 4%) 1% or 2% Lidocaine with or without epinephrine Topical Hemostatics: absorbable gelatin, microfibrillar collagen, oxidized cellulose, neo-synephrine preparations Packing dressing may be impregnated with antibiotic or vaseline Anti-inflammatories - Afrin (pseudoephedrine) Positioning Supine with General Anesthesia Modified Fowlers with Local Anesthesia Pillow under head

Arms tucked or secured across chest Footboard with Fowlers Safety strap Prep Nare hair clipping Eye protection Mild antiseptic on face Cotton tipped applicator nostril cleansing Begins at upper lip, beyond hairline, below chin Prevent prep solution from entering eyes

Draping Turban like head wrap 3 triangle folded towels Forehead bar towel or sheet Split sheet Body drape Supplies, Equipment, Instrumentation

Nasal or septum Medicine

cups speculum 2 local syringes Bayonet forceps 2 25 scissors Small or 27gauge (Joseph) needles Long cotton tipped applicators Curettes Packing Skin hooks

gauze, cotton, or cottonoids Headlight 6, 30, 70 endoscopes Microscope Nasal chisel & mallet Nasal dressing forceps Hartman nasal forceps Septal knife (Joseph or Cottle) Ballenger swivel knife Freer elevator Nasal Rasp (Foman) Fine suction tips (irrigate often)

Considerations Ear and Nasal Surgery not truly sterile surgical procedures, however, aseptic technique imperative to prevent infection Oral Cavity and Throat Terminology of the Oral Cavity & Throat

Pharynx-(throat) beginstonsils Adenoids-(pharyngeal at internal if enlarged) nares and lymphatic ends posterior

tissue in to nasopharynx the larynx (atrophies where it joins withthe age) esophagus Epiglottis-small structureofatthe Stomatitis-inflammation back mouth of throat, covers larynx when swallowing

Fauces-opening Thyroid cartilage-(Adams of the oropharynx apple) Glottis-space between Trachea-(airway) cartilaginous the vocaltube cords extending from the larynx to the bronchial tubes Larynx (voice

box) cartilaginous structure above the trachea, houses the vocal cords Vocal cords-fibrous bands of tissue, stretched across the hollow interior of the larynxtonsils-lymphatic which vibrate tooval create soundof tissue in the oropharynx Palatine masses Papilloma-benign epithelial tumor Anatomy of the Upper

Aerodigestive Tract Pharynx 1. Nasopharynx nares to uvula Eustachian tubes auditory tube Pharyngeal tonsils enlarged called Salivary glands

Sublingual under tongue Submandibular under jawbone Parotid largest / in front of mastoid process and below zygomatic arch adenoids 2. Oropharynx uvula to hyoid

(tongue base) Palatine tonsils back of oropharynx Lingual tonsils base of tongue 3. Laryngopharynx hyoid to larynx/esophageal bifurcation Larynx voicebox Trachea Bronchi & Lungs

Esophagus Tonsillectomy removal of palatine tonsils Adenoidectomy removal of pharyngeal tonsils

Parotidectomy risk of Facial nerve (VII) damage due to its proximity to the parotid gland Physiology of Taste

Gustatory sense = taste Bipolar neurons in taste buds 4 chemicals detected: sweet, sour, salt, bitter Taste related to smell Taste detected 2/3 anterior taste buds from facial nerve (VII), 1/3 posterior tongue from glossopharyngeal nerve (IX) Are most sensitive to bitter Takes a lot of sweet to detect

Interpreted in cerebrum Pathology of the Upper Aerodigestive Tract Polyps Pharyngitis Vocal Epiglottitis cord nodules Laryngeal Tonsillitis neoplasms Tumor Peritonsillar abscess Tracheitis

Sleep apnea Bronchitis Foreign bodies Croup Laryngitis Pathology of the Esophagus Esophagitis Ulceration Neoplasms Foreign bodies Zenkers diverticulum located in esophagus dx w/ esophagoscopy - 1sx

dysphagia Esophageal varices - esophagus erodes due to severe alcoholism Diagnostic Testing Direct Visualization Culture & Sensitivity (C&S) CBC X-Ray CT Scan MRI Endoscopy

Anesthesia General Site of intubation typically opposite that of operative site (nose verses throat) MAC with IV Sedation Local Anesthesia Anesthetic considerations No pure oxygen Risk of fire especially with laser use Laser-safe ET tube

Medications Steroids per anesthesia Anti-inflammatories (Afrin) Water soluble lubricant Topical anesthetics: Lidocaine jelly lubricant, (Cetacaine spray, 4% cocaine (topical ONLY)

Local anesthetics: Lidocaine or Marcaine with or without epinephrine Topical hemostatics: Gelfoam, neo-synephrine Positioning Supine Sitting Arms tucked Shoulder roll Head support (donut) Pillow under knees Safety strap

Prep None to extensive Surgeons preference Draping Head wrap Towels Impervious drape (Ioban) Fenestrated sheet U-sheet None

Supplies, Equipment, Instrumentation

Headlight Basic pack Basin set ECU Raytex Microscope Tonsil sponges Endoscopes

(rigid or flexible) Cottonoids Video tower Small basin CO 2 or Nd:YAG laser Suction tubing Mouth gag Suctionsnare tip (fine) Tonsil

Blade choice Dentaloforsurgeon laryngeal mirror(#12) Cautery Biopsy forceps Suction/cautery Alligator forceps Plain, vicryl, silk suture or reels Curettes Lukens

specimen Fisher tonsil knife trap Lubricantor Malonies Bougies Specimen container Tongue depressor Lasers CO2

Nd-Yag Most commonly used Superficial tissue not clear liquids Effect dependent on heat build-up Invisible beam Use helium + neon (He-Ne beam) red beam as aiming source

Most powerful and precise Fiber delivered Contact or noncontact modes Transmissible thru fluids Invisible beam Use helium + neon (He-Ne beam) or white light as aiming source

Post-operative Considerations Laryngospasm Keep backtable sterile until patient extubated and you receive CRNA clearance Sore throat Hoarse Bleeding Be aware of ET tube as drapes removed Infection

Endoscopies Endoscopies

Laryngoscopy Microlaryngoscopy Bronchoscopy Esophagoscopy Endoscopes: Rigid larger viewing surface Flexible easy insertion and manipulation For: diagnostic or operative use: cytology (cultures), biopsy, foreign body removal, bougie or maloney (esophageal dilators) insertion Review Cytology cell type only Biopsy for frozen or permanent

Permanent specimen delivery to pathology not urgent, is obvious, or pathology has already been diagnosed Frozen specimen immediate tissue identification or malignancy identification is needed Tissue to go dry or on a telfa NEVER a counted sponge NEVER placed in solution (saline or Formalin)

Laryngoscopes L-shaped intubation Flexible assist with intubation, diagnostic, biopsy Rigid U-shaped biopsy, foreign body removal, vocal cord procedures Microlaryngoscopy

Laryngoscopy Microscope (400mm focal length=40cm focal length) Microlaryngeal instruments (22cm) Laser attached to microscope CO2 single beam, more precise (used with helium-neon beam to provide red beam for proper aiming) Vocal cord, tracheal, bronchial lesions Nd: YAG Laser tracheal or bronchial lesions Bronchoscopes

Flexible Rigid Longer than laryngoscopes Adaptor required for oxygenation Nd: YAG (prn) Esophagoscope

Flexible Used with flexible gastroscope (EGD) Rigid Flared at distal end due to collapsibility of esophagus (better visibility) Nd: YAG laser (prn) Diagnostic for: esophageal cancer, hiatal hernia, stricture, stenosis, esophageal varices, tumor Triple Endoscopy/Panendoscopy Triple Endoscopy or Panendoscopy Term describes all three procedures

combined: Esophagoscopy Laryngoscopy Bronchoscopy Diagnostic Thyroid and Parathyroid Glands Thyroid and Parathyroid Surgery 1 performed by general surgeons

Thyroid Gland 2 lobes Anterior to larynx Connected by isthmus at 2nd tracheal ring H-shaped Two hormonal cell types: Follicular produce, store, release

Thyroxine and Triidothyronine Are basal metabolic rate regulation hormones Parafollicular secrete Calcitonin Hormone that maintains calcium homeostasis

Parathyroid Glands Numbered 1 to 6 Small, flat, oval dorsal to thyroid gland Hormone - Produce Parathormone which maintains a normal blood and skeletal calcium relationship Cannot remove all of them due to certain tetany and death

May see some re-implanted elsewhere in body (thigh, upper arm) Pathology of Thyroid and Parathyroid Glands Hyperthyroidism: restlessness, fast speech, tachycardia, palpitations, arrythmias, dyspnea, heat intolerance, diaphoresis, weakness, tremor,

hair loss Hyperparathyroidism: asymptomatic to skeletal damage Thyroid carcinoma: signs of hyperthyroidism, hypothyroidism, hoarseness, difficulty swallowing, dyspnea Diagnostic Testing Physical Exam Serum TSH levels Ultrasound Biopsy CT Scan MRI

Laryngoscopy Anesthesia General Medications Lidocaine with or without epinephrine Bupivicaine with or without epinephrine Antibiotic irrigation Topical hemostatic agents

Positioning Supine Donut headrest Shoulder roll Arms tucked Pillow under knees Safety strap Prep Surgeons preference: Duraprep, Betadine scrub and/or paint End of chin to midchest and bedsheet to

bedsheet Draping Towels Small fenestrated sheet (Pediatric sheet) Thyroid sheet U-Sheet Surgeons preference Supplies, Equipment, Instrumentation

Minor basin Basic pack Blades of choice Suture of choice Silk ties

penrose Bipolar forceps Headlight Minor Tray Headlight Minor tray Post-operative Considerations Will need medical hormonal therapy Potential damage to bilateral laryngeal

nerve with dissection Hemorrhage Infection Laryngeal edema Tracheotomy & Tracheostomy Tracheotomy/Tracheostomy

Tracheotomy temporary opening into the trachea to facilitate breathing Tracheostomy permanent opening of the trachea and creation of a tracheal stoma Must place tracheal tube with either Patient will be hooked up to a ventilator Long term tracheostomy may eventually be able to wean off ventilator, but maintain stoma that will function as their nose did prior to surgery Indications For Tracheotomy or Tracheostomy

Vocal cord paralysis Neck surgery Trauma Prolonged intubation Secretion management Cannot intubate

Stridor due to tracheal blockage Sleep apnea Anesthesia General Local Medications Local anesthetic: Lidocaine or bupivicaine with or without epinephrine Antibiotic irrigation

Positioning Supine Shoulder roll Donut headrest Pillow under knees Safety strap Prep End of chin to midchest and bedsheet to bedsheet Prep of choice: Duraprep, betadine scrub and/or paint

Draping Towels Small fenestrated sheet (Pediatric lap sheet) Supplies, Equipment, Instruments

Tracheotomy Minor basin tray Basic pack tube (Shiley) Tracheotomy Pediatric Twill tapelap sheet Other small fenestrated sheet Blades Suture or ties of surgeons choice (prn) Considerations

Will make sure obturator goes with patient to PACU or ICU Complications: hemorrhage, infection, laryngeal edema, damage to other structures Summary

Terms Ear Nose A &P Throat Pathology Endoscopy& Meds Anesthesia Triple endoscopy Positioning, Prep, & Draping

Thyroid &Equipment, Supplies, Parathyroids & Instrumentation Tracheotomy & Complications Considerations

Recently Viewed Presentations

  • Main Idea and Details - williston.k12.sc.us

    Main Idea and Details - williston.k12.sc.us

    Main Idea and Details What is the Main Idea? What are the Supporting Details? Let's take a look… Let's take a look… Let's take a look… Fossils Fossils are important clues to our past. Fossils are remains of plants or...
  • PowerPoint Template - Clark County School District

    PowerPoint Template - Clark County School District

    Mention they will see a pattern as we move throughout the day as you will be given time for reflection and time for work, very much like the school improvement cycle and the theory of action. Joe used a football...
  • The Purpose of Mortality in the Great Plan of Happiness

    The Purpose of Mortality in the Great Plan of Happiness

    D&C 101:32-33 [Speaking of the millennium] Yea, verily I say unto you, in that day when the Lord shall come, he shall reveal all things --Things which have passed, and hidden things which no man knew, things of the earth,...
  • Accessing Reduction of Nonpoint Source Phosphorous Runoff ...

    Accessing Reduction of Nonpoint Source Phosphorous Runoff ...

    Accessing Reduction of Nonpoint Source Phosphorous Runoff From Land Application of Biosolids Treated With Water Treatment Residuals Project # FY 07-200
  • Online Strategy and Extended Chat Services for Campus

    Online Strategy and Extended Chat Services for Campus

    Through the "Ask Us" service that is available on every page, individuals can connect with staff by web chat, email and request forms. Staff can find info, discuss what it means, answer questions, recommend next steps and make warm transfers...
  • kovan.ceng.metu.edu.tr


    Mechanisms in Procedures. Passing control. To beginning of procedure code. Back to return point. Passing data. Procedure arguments. Return value. Memory management. Allocate durin
  • DGs at D0

    DGs at D0

    Arial Times New Roman Symbol Monotype Corsiva Wingdings PMingLiU Default Design Microsoft Equation 3.0 Lifetime Difference ( = 1/ ) in the Bs System Old (PRL 2005) and New Analyses CKM Matrix and Unitarity triangle Bs System and CP violation...
  • Antibody Titration - Islamic University of Gaza

    Antibody Titration - Islamic University of Gaza

    ANTIBODY TITRATION Mr . Mohammed A. Jaber Principle Titration is a semiquantitative method used to determine the concentration of antibody in a serum sample or to compare the strength of antigen expression on different red cell samples.