Ent Instruments With Details

Freer’s Elevator

This instrument is an important part of the septoplasty set. Uses of the Freer’s elevator:

• • • •

Elevation of mucoperichondrial/mucoperiosteal flaps in septoplasty or SMR Separation of the septal cartilage from bone during septoplasty To perform uncinectomy during endoscopic sinus surgery For mucoperiosteal flap elevation in endonasal DCR

Identifying the septal elevator This is a thin and long instrument with small flattened blades at either end. Most elevators are straight at one end and slightly curved at the other.

This is a close up of one end of the septal elevator. Differentiating it from the tonsillar dissector The tonsillar dissector is also a long and thin instrument, one end of which looks very much like the Freer’s elevator. Here’s how to tell the two instruments apart. • • •

The tonsillar dissector is slightly longer and stouter than the septal elevator. It has a blade on one end that is similar to the ones on the Freer’s elevator, but slightly larger. But the other end is bent and serrated with a comb like appearance.

How to use the Freer’s elevator The straight end may be used for elevation of flaps. The curved end may be used in septoplasty to separate the quadrilateral cartilage from bone and elevate the mucoperiosteal flap on the opposite side. The curved end may also be used to make an incision at the attachment of the uncinate process to the lateral wall of the nose during uncinectomy. (This is one method of performing uncinectomy, there are several others.) Both ends of the instrument are usually sharp, a feature that helps flap elevation and sharp dissection.

If you look closely at the blade, you will find that one surface is flat and the other is gently curved. During flap elevation in septoplasty, make sure the flat surface and the sharp end rest on the cartilage or bone, while the smooth, curved side faces the flap. This will help you apply pressure on the septum without tearing the flap. More information:

The elevator is used even in endoscopic septoplasty. Modifications of the elevator with provision for suction are available. Bleeding during flap elevation is common and this instrument helps provide a clear field. This instrument is also handy in any procedure that involves dissecting soft tissue off cartilage or bone. .

Lack's Tongue Depressor

This is a very commonly used OPD instrument. It has two blades at right angles to each other. One of them is slightly wider than the other and is completely flat. This is the part of the tongue depressor that is inserted into the oral cavity. The other blade is narrower and has a slight curve at its free end, like a handle. This is the part of the instrument that is held in your hand. Uses of the tongue depressor: Examination of the oral cavity – vestibule, buccal mucosa, gums, floor of the mouth Examination of the oropharynx and posterior pharyngeal wall Used in posterior rhinoscopy, along with the postnasal mirror For the ‘cold spatula test’ – to assess (approximately) the nasal airway/ patency in the OPD To perform minor procedures in the oral cavity To take a throat swab or a swab from the tonsil How to use the tongue depressor: Hold the instrument by the narrower blade that acts as a handle. Insert the other blade into the oral cavity.

First retract the cheek so you can examine the vestibule, buccal mucosa and gums and repeat the same on the other side. Then place the blade flatly on the dorsum of the tongue and press it down – this will allow you to examine the palate, tonsillar pillars, the tonsils and the posterior pharyngeal wall. Take care to depress only the anterior two-thirds of the tongue with this instrument. Touching the posterior third of the tongue will elicit the gag reflex.

Tilley's Nasal Dressing Forceps

This nasal instrument has important functions in both the OPD and the operating room. It is also called the packing forceps or dressing forceps. No nasal surgery set is complete without these forceps. Uses of the nasal dressing forceps: To perform anterior nasal packing To remove foreign bodies, crusts or packs from the nose To pack the nose with gauze strips during nasal surgeries or sinus surgeries To remove cartilage and bone pieces during septoplasty or SMR Identifying the nasal packing forceps: Like most nasal instruments, these forceps are bent at an angle so the hand grasping the instrument doesn't obstruct the vision of the examiner. The blades are long and thin so they can be easily inserted into the nasal cavities. Differentiating nasal and aural forceps: Both instruments are very similar to look at. The difference is in the tip. Aural forceps have tips that are triangular while the tip of the nasal forceps is straight and serrated. The serrations give grip to the instrument and help grasp the various objects mentioned above.

Nasal Foreign Body Hook

This is an instrument used in the outpatient to remove foreign bodies from the nose. Nasal foreign bodies are common in children and in mentally retarded or disturbed individuals. The usual foreign bodies seen are small objects like beads, seeds, chalk piece or even stones. Foreign bodies in the nose cause symptoms like nasal obstruction and discharge. Children often present with a history of unilateral, foul-smelling and/or blood stained nasal discharge. Anterior rhinoscopy may reveal the foreign body, covered with slough or discharge. Long standing foreign bodies in the nose sometimes get covered by deposits of salts and slough and become rhinoliths. How is the foreign body removed It is important to pass the tip of the instrument over and beyond where the object is lodged in the nose so that it can be hooked and drawn forward along the floor of the nasal cavity.

If you look closely, you will find that one end of the foreign body hook is shaped like a ring.

The other end is a curette, shaped like a spoon. Differentiating it from the Jobson Horne wax hook: The Jobson Horne wax hook is a similar looking instrument used to remove wax and foreign bodies from the ear. Here's how to tell the nasal foreign body hook and the wax hook apart. • • •

The nasal hook is shorter and stouter than the ear hook. One end of both instruments is ring shaped, but the ring on the wax hook is smaller and more delicate. The other end of the nasal hook is spoon-shaped while it is thin and sharp in the case of the wax hook.

Other methods of removing nasal foreign bodies: • • •

Earlier, an instrument called the Eustachian catheter, one end of which is slightly bent, was used to hook out the foreign body. Using the endoscope and endoscopic instruments. In very small and uncooperative children, the foreign body is better removed under general anesthesia.

Jobson-Horne Ear Probe

This is a commonly used OPD instrument and is also called the wax hook or ring curette.

Uses: Ear wax removal Removal of foreign body from the ear Removal of otomycotic debris or discharge from the external auditory canal Probing of aural polyp or other mass in the ear canal Probing of nasal masses and checking their sensitivity to touch

If you look closely, you will find that one end of the probe is shaped like a ring. This end may be used to hook out wax or foreign bodies from the ear canal.

The other end of the instrument is sharp and serrated. An ear wick can be fashioned out of this end by rolling cotton on to it and used to mop ear discharge.

More Information:

• •

If wax in the ear canal is impacted, it is better to first soften it with wax-softening or dissolving agents and then attempt to remove it. Wax in the ear canal can also be removed by syringing using an aural syringe or by using suction apparatus under microscopic visualization.

Indirect Laryngoscopy Mirror

This mirror is used to examine the larynx in the outpatient using a procedure called indirect laryngoscopy. How indirect laryngoscopy is done: • • • • • •

The indirect laryngoscopy mirror is warmed to avoid fogging on it. The patient is asked to protrude his/her tongue which is then held with a piece of guaze. The patient is directed to breathe through his/her mouth. The warmed indirect laryngoscopy mirror is then introduced into the oral cavity with the mirror facing downwards. (Check its temperature by touching the back of your hand with it, it should not be hot.) The mirror is brought to rest against the uvula but do not touch the posterior pharyngeal wall to avoid setting off the gag reflex. Once the laryngeal inlet is visualized, the patient is asked to say ‘eee’ to check the movement of the vocal cords.

Structures seen on indirect laryngoscopy (in order):

• • • • • • • • • •

Base of the tongue (posterior one-third of the tongue) Vallecula Median and lateral glossoepiglottic folds Epiglottis Pharyngoepiglottic folds Aryepiglottic folds Arytenoids False vocal cords True vocal cords Tracheal rings

Indications for indirect laryngoscopy:

•

Examination of the larynx in cases of change in voice

• • •

Examination for dysphagia To look for vocal cord mobility prior to thyroid surgery To look for the primary in cases of neck metastases

The shaft of the indirect laryngoscopy mirror is straight, a feature which helps differentiate it from the posterior rhinoscopy mirror which has a bent shaft. More information:

• • •

The mirror is available in 5 sizes, the smallest is 1 and the largest 5. Indirect laryngoscopy was first performed by Manuel Garcia, a singer. Using flexible fibreoptic laryngoscopy is another method of examining the larynx in the OPD.

Nasal Speculum - Thudichum's

The Thudichum’s nasal speculum is an instrument routinely used in the outpatient to examine the nose.

The instrument has two flanges that can be inserted into the nostril during anterior rhinoscopy. The flanges widen to open up the nasal cavity, offering a better view of the structures inside the nose. Uses of the Thudichum’s nasal speculum: • • • •

In anterior rhinoscopy Foreign body removal from the nose Peroperatively, for nasal packing In septal surgeries (septoplasty and SMR) while making the incision

How to use the Thudicum’s nasal speculum:

First, hold the instrument at its bend with your thumb and index finger.

Then, place your middle and ring fingers either side of the limbs of the speculum. Bringing these fingers close to each other will also bring the flanges of the speculum close together. Insert the instrument into the nostril in this position. Moving your middle and ring fingers apart will widen the flanges of the speculum, opening up the nasal cavity in the process. More Information: • • •

Insert the speculum fully closed into the nasal cavity, but keep the flanges slightly open while drawing the speculum out to avoid pulling any vibrissae! Practice using the Thudicum’s speculum during your clinical posting, the method described above is the optimal way to best visualize the nasal cavity. Structures seen on anterior rhinoscopy:

- Nasal septum - Lateral wall of the nose including the turbinates and the meati - Floor of the nasal cavity •

Do not use the nasal speculum to examine the vestibule. Just lift up the tip of the nose with your finger to look at the vestibule of the nose, using the speculum will only obscure it from your vision.

Tuning Forks

In ENT, tuning forks are used to clinically test hearing and identify the type of hearing loss. The parts of a tuning fork are: • • •

Base plate or footplate Shaft Prongs that vibrate producing sound

If you look at the shaft or the footplate closely, you will find it carries a number - this is the frequency at which the tuning fork vibrates and is denoted in Hertz (Hz). The commonly used tuning forks to test hearing are 256 Hz, 512 Hz and 1024 Hz. These frequencies correspond to the speech frequencies. Tuning forks of lower frequencies (like 128 Hz) produce vibrations that are felt more than they are heard, while those of higher frequencies produce more overtones. More information: • • • •

Tests done with these tuning forks include Rinne's, Weber's and the absolute bone conduction test. Other tests, not routinely performed, are the Bing's test, Stenger's, Gelle's and Chimani Moos test. If you have to perform these tests with a single tuning fork, pick the 512 Hz. To set the tuning fork into vibration, always strike it against a firm but yielding surface like your elbow and not hard surfaces like table tops.

Aural Syringe

This instrument is the metallic aural syringe, an instrument used for syringing of the ear, an OPD procedure. Indications for ear syringing: • • •

Wax removal Foreign body removal Removal of otomycotic debris

The syringe has a nozzle for insertion into the external auditory canal. Water at body temperature is loaded into the syringe. The syringe is held by inserting fingers into the rings at the back. The third ring is on the piston that forces the water out when pushed. More Information: • • •

Syringing should be avoided in case of perforated tympanic membrane. Aural syringing can result in complications like trauma to the external auditory canal and perforation of the tympanic membrane. Other methods of wax and foreign body removal include manual removal using the Jobson-Horne wax hook, suction and removal under microscope.

Trousseau’s Tracheal Dilator

This instrument is a part of the tracheostomy set. It should be available not only in the OR but also in the emergency/casualty. Uses of the tracheal dilator It is basically used to widen the tracheal opening while inserting a tracheostomy tube • •

Peroperatively during tracheostomy During a tube change

It is especially useful should the tube accidentally come off in the early post op period, when the track is still not well formed. Identifying the instrument It looks like a pair of regular artery forceps except that • • •

Its tip is bent at almost right angles to the rest of the instrument There is no lock or clasp The tip is smooth and rounded unlike the sharp, dissecting tip of the artery forceps

Note how the tip of the dilator is bent at right angles to the rest of the body. This helps reach the tracheal opening located at a depth in the neck.

Notice how bringing your fingers together actually opens the tracheal dilator. The instrument has a spring action to keep it closed; the prongs will remain open only as long as you hold them apart. How to use the tracheal dilator The instrument is held by inserting your thumb and index fingers into the rings provided. When using regular artery or Allis forceps, if you bring your thumb and index fingers together, the prongs of the instrument also move inwards and close. But with the tracheal dilator, when you bring your two fingers together, the prongs at the tip of the instrument move away from each other. So hold the instrument, insert the tip into the tracheal stoma and bring your fingers together. This will help you widen the tracheal opening so you can slide in the tracheostomy tube. More information

• •

•

Stay sutures may be placed on either side of the tracheal opening. Pulling on these sutures will help to hold open the stoma and to pull it up to the level of the skin, facilitating tube insertion or change. Structures to be divided before the trachea can be reached: o Skin o Subcutaneous tissue o Strap muscles o Isthmus of the thyroid o Pretracheal fascia How to prevent accidental displacement of the tracheotomy tube before the track is formed o Correct placement of the tube o Firmly securing the tube – the tube may even be secured with sutures