536 TaBle 1 Tumor nodal metastasis classification and – Clinically N0 neck: Level VI should be always
staging of thyroid carcinoma dissected, and levels II–V and VII must be palpated
during surgery.
Primary tumor (T)
– Clinically N1 neck (levels II–V): Selective neck dissec-
Section 7 w Neck Tx Unable to assess primary tumor tion involving these levels; modified radical, radical
T0 No evidence of primary tumor or extended radical neck dissection depending on
T1 Intrathyroid tumor up to 1 cm greatest dimension the size and extent of disease.
T2 Intrathyroid tumor more than 1 cm, and less than 4
Postoperative external beam radiotherapy: It is indi-
cm in greatest dimension cated when operative clearance is doubtful, or in cases
of extensive nodal involvement.
T3 Intrathyroid tumor more than 4 cm in greatest
dimension Medullary carcinoma: It needs total thyroidectomy with
modified radical or radical neck dissection, which may need
T4 Tumor extending beyond thyroid capsule to be extended into superior mediastinum.
Regional lymphadenopathy (N) (cervical and upper Postoperative external beam radiotherapy: It is indi-
mediastinal nodes) cated when operative clearance is doubtful, or in cases
of extensive nodal involvement with extracapsular
Nx Unable to assess regional lymph nodes extension.
N0 No evidence of regional metastasis 131I-MIBG: It may be used in cases of recurrence or
N1a Metastasis in ipsilateral cervical lymph node metastasis.
N1b Metastasis in bilateral, contralateral, or midline
Lymphoma: Radiotherapy is the main treatment for this
cervical or mediastinal lymph nodes lesion.
Chemotherapy: It is indicated in high-grade histology
Distant metastases (M) and more advanced disease.
Mx Unable to assess for distant metastases Anaplastic carcinoma: Unfortunately, no treatment is effec-
M0 No distant metastases tive in this thyroid cancer. Radiotherapy achieves regression
M1 Distant metastases but early recurrence usually occurs. Patient with stridor
TNM staging (under 45 years)* for papillary and follicular needs isthmus split tracheostomy.
carcinoma
Prognostic factors of thyroid carcinoma are the following:
Stage I Any T, any N, and M0 • Age: Patients under 45 years of age do better.
Stage II Any T, any N, and M1 • Sex: Females do better.
TNM staging (over 45 years) for papillary, follicular and • TNM staging: Higher the stage, poorer is the prognosis.
medullary carcinoma • Histology: Tall cell variant of papillary carcinoma and marked
Stage I T1 N0 M0 invasion of follicular carcinoma have poorer prognosis.
Stage II T2-3 N0 M0
Stage III T4 N0 M0; T1-4 N1 M0 Anaplastic carcinoma has very poor prognosis.
Stage IV T1-4 N0-1 M1 • Treatment: Delay treatment, extensive surgeries and
TNM staging for anaplastic carcinoma
inadequate facilities offer poorer prognosis.
Stage IV Any T, any N and any M • Surgeon: Experienced surgeon can offer best treatment.
* Patients under 45 years of age do not have stage III and IV.
clinical highlights
1. carotid body tumor: Embryologically it is believed to originate from neural-crest cell.
2. lyre sign: Splaying apart of internal and external carotid arteries by carotid body tumor and seen on carotid angiography.
3. Second arch branchial fistula: Its external opening lies along the anterior border of sternocleidomastoid muscle. The
fistulous tract passes deep to digastric muscle between the internal and external carotid arteries.
4. extranodal lymphoma: It is a common manifestation of non-Hodgkin’s lymphoma.
5. Thyroglossal cyst: Arises from remnants of thyroglossal duct.
6. Biopsy: Thyroid lymphoma and anaplastic carcinoma need open biopsy before the beginning of therapy.
7. papillary and follicular carcinoma of thyroid: Low-risk patients are females under 45 years and high-risk patients
are all males, and over 45 years females. Low-risk tumors include less than 1 cm size papillary and minimally invasive
follicular carcinoma. High-risk tumors include more than 1 cm size papillary and follicular carcinomas. Multifocality, local
or distant spread are also risk factors.
FUrTher readiNg
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2. Aslam M, Hasan SM, Hasan SA. Fine needle aspiration cytology (FNAC) versus histopathology in cervical lymphadenopathy. Indian J
Otolaryngol Head Neck Surg. 2000;52:137-40.
3. Bist SS, Bisht M, Varshney S, et al. Thyroglossal duct cyst in hyoid bone: Unusual location. Indian J Otolaryngol Head Neck Surg.
2007;59:366-8.
4. Chakravarthy VK, Rao NDC, Chandra ST. Study of papillary carcinoma of thyroid with uncommon sites of metastasis. Indian J Otolaryngol 537
Head Neck Surg. 2010;62:198-201.
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6. D’Souza O, Hasan S, Chary G, et al. Cervical lymph node metastases in head and neck malignancy—a clinical/ultrasonographic/
histopathological comparative study. Indian J Otolaryngol Head Neck Surg. 2003;55:90-3.
7. Dabholkar JP, Patole AD, Sheth AS, et al. Congenital cystic lesions in head and neck. Indian J Otolaryngol Head Neck Surg. 2003;55:128-30.
8. Ghosh A, Saha S, Pal S, et al. Peripheral primitive neuroectodermal tumor of head-neck region: our experience: Indian J Otolaryngol
Head Neck Surg. 2009;61:235-9.
9. Hemaraju N, Nanda SK, Shankar B, et al. Second branchial sinus—a case report. Indian J Otolaryngol Head Neck Surg. 2006;58:198-200.
10. Kale US, Carlin J. Toxoplasmosis as a rare cause of symptomatic cervical lymphadenopathy. Indian J Otolaryngol Head Neck Surg.
2000;52:261-3.
11. Kameshwaran M, Natrajan K, Kumar A, et al. Unusual presentation of a giant glomus tumor. Indian J Otolaryngol Head Neck Surg.
2003;55:196-9.
12. Mehta MR. Cystic hygroma: Presentation of two cases with a review of the literature. Indian J Otolaryngol Head Neck Surg. 2000;52:319-22.
13. Nitnaware AZ, Sakhare PT, Kapre GM. Cystic Hygroma with Extensive Tongue Involvement. India J Otolaryngol Head and Neck Surg.
2011;63:89-92.
14. Prasad SC, Thada N, Pallavi, et al. Paragangliomas of the Head & Neck: the KMC experience. India J Otolaryngol Head and Neck Surg.
2011;63:62-73.
15. Ragesh KP, Chana RS, Varshney PK, et al. Head and neck masses in children: A clinicopathological study. Indian J Otolaryngol Head Neck
Surg. 2002;54:268-71.
16. Rao GM, Janaki M, Kumar SVL. Carotid body paraganglioma. Indian J. Otology Special Issue-I. 2005;324-5.
17. Rao K, Goyal VP. Comparative Study of FNAC and Excisional Biopsy in Thyroid Swelling. Indian J Otolaryngol Head Neck Surg. 2010;62:415-6.
18. Rashid MA, Mondal AR, Mondal PK, et al. Extranodal lymphoma. Indian J Otolaryngol Head Neck Surg. 2001;53:145-7.
19. Rawat JD, Sinha SK, Kanojia RP, et al. Non surgical management of cystic lymphangioma. Indian J Otolaryngol Head Neck Surg.
2006;58:355-7.
20. Samiullah, Aslam M, Hasan SA, et al. Fine needle aspiration cytology vs biopsy in head and neck swellings. Indian J Otolaryngol Head
Neck Surg. Special issue-I. 2005;24-5.
21. Santosh M, Rajashekhar B. Perceptual and Acoustic Analysis of Voice in Individuals with Total Thyroidectomy: Pre-post Surgery
Comparison. India J Otolaryngol Head and Neck Surg. 2011;63:32-9.
22. Sengupta A, Das S, Chakrabarty S. Diagnostic dilemma in bilateral multiple cervical lymphadenopathy. Indian J Otolaryngol Head Neck
Surg. 2005;57:56-8.
23. Shekhar C, Kumar R, Kumar R, et al. The complete branchial fistula: A case report. Indian J Otolaryngol Head Neck Surg. 2005;57:320-2.
24. Shenoy AM, Ashok H, Hari Prasad AV, et al. Neck metastasis from unknown origin—results of planned primary surgery and postoperative
radiation therapy. Indian J Otolaryngol Head Neck Surg. 2001;53:213-6.
25. Showkat SA, Lateef M, Wani AA, et al. Clinicopathological profile of cervicofacial masses in pediatric patients: Indian J Otolaryngol Head
Neck surg. 2009;61:141-6.
26. Sinha V, Hirani N, Memon R, et al. Study of anomalies of thyroglossal tract. Indian J Otolaryngol Head Neck Surg. 2003;55:174-5.
27. Sra N, Verma SK, Singh D, et al. Incidence of lymphomas in head and neck region. Indian J Otolaryngol Head Neck Surg. 2003;55:303-5.
28. Srivalli M, Qaiyum HA, Moorthy PNS, et al. A case report of cervical thymic cyst and review of literature. India J Otolaryngol Head and
Neck Surg. 2011;63:93-5.
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30. Management of tuberculous lymph nodes in the neck? Reader’s Forum-21. Indian J Otolaryngol Head Neck Surg. 2000;52:328-9.
54 Deep Neck Infections
Make your nerves strong. What you need is muscles of iron and nerves of steel. You have wept long enough. No more weeping, but
stand on your feet and be men. Have faith in yourself. You all have infinite power in you. Rouse that up; arise, arise—apply yourselves
heart and soul, gird up your loins.
—Swami Vivekananda
Points of focus ¯ inVeStigAtionS
¯ treAtment
¯ Pertinent AnAtomy
Peritonsillar space Antibiotic Therapy
Parapharyngeal space surgical Drainage
Retropharyngeal space ¯ PeritonSillAr infectionS
Danger space ¯ PArAPhAryngeAl SPAce AbSceSS
Prevertebral space ¯ Acute retroPhAryngeAl AbSceSS
submandibular space ¯ PreVertebrAl SPAce AbSceSS
space of Body of Mandible ¯ ludwig’S AnginA
Masticator space ¯ AbSceSS of SPAce of body of mAndible
submandibular space ¯ mASticAtor SPAce AbSceSS
Masticator space ¯ triSmuS
¯ clinicAl highlightS
¯ SourceS of infectionS
¯ microbiology
¯ clinicAl feAtureS
Deep space neck infections are potentially lethal infections is the lateral wall of the peritonsillar space. It is formed by the
and need immediate appropriate treatment. These spaces are superior constrictor muscle.
situated between the three layers of deep cervical fascia which
have been described in chapter“Anatomy of Neck.”On the basis Parapharyngeal Space or Pharyngomaxillary
of hyoid bone, deep neck spaces can be divided into several
groups (Box 1). Space or lateral Pharyngeal Space
This pyramid-shaped space has its base towards the skull base
Pertinent AnAtomy while its apex towards the hyoid bone.
Figure 1 shows the sites of various deep neck space abscesses. Boundaries
Peritonsillar Space Medial: Buccopharyngeal fascia, which covers the supe-
It is situated between the capsule of tonsil and the superior rior constrictor muscles. Medial wall of the parapharyn-
constrictor muscle. Medial wall of the parapharyngeal space geal space is the lateral wall of the peritonsillar space.
Posterior: Prevertebral fascia, which covers preverte-
bral muscles and transverse processes of the cervical
vertebrae.
box 1: Classification of deep neck spaces Compartments 539
• suprahyoid Styloid process and the structures attached to it divide the
parapharyngeal space into anterior and posterior compart- chapter 54 w deep neck infections
– Face ments.
◊ Buccal Anterior compartment: It is medially related to the
◊ Canine tonsillar fossa, and laterally to the medial pterygoid
◊ space of body of mandible muscle.
◊ Masticator Posterior compartment: It is related medially to the
- Masseteric posterior part of lateral pharyngeal wall, and laterally
- Temporal to the parotid gland. The contents of this compartment
- Pterygoid are the following structures:
◊ Temporal – Internal carotid artery
◊ Parotid – Internal jugular vein
– Cranial nerves 9th, 10th, 11th and 12th
– Neck – Sympathetic trunk
◊ Peritonsillar – Upper deep cervical nodes
◊ Parapharyngeal
◊ submandibular Communications: Parapharyngeal space communicates with
- sublingual space (superior) the following spaces:
- submaxillary space (inferior) Retropharyngeal
Submandibular
• Infrahyoid Parotid
– Visceral Carotid
Visceral
• Entire length of neck
– Vascular: Carotid sheath retropharyngeal Space
– Prevertebral Boundaries and Extent:
– Danger space or alar space
– Retropharyngeal The retropharyngeal space lies between the bucco-
pharyngeal fascia covering the pharyngeal constrictor
muscles, and the prevertebral fascia covering the verte-
brae and prevertebral muscles.
It extends from the skull base to the bifurcation of
trachea in mediastinum.
Compartments:
A midline fibrous raphe divides this space into two
lateral compartments (spaces of Gillette); one on each
side.
An abscess of retropharyngeal space causes unilateral
bulge.
Contents:
The space contains retropharyngeal nodes, which
usually disappear at 3–4 years of age.
Communications:
The retropharyngeal space communicates with the
parapharyngeal space.
Retropharyngeal space infection may pass down into
the mediastinum behind the esophagus.
fig. 1: Deep neck spaces for abscesses danger Space
Abbreviations: CN, Cranial nerves IX, X, XI and XII and sym- It lies just posterior to retropharyngeal space in between the
pathetic trunk; IC, Internal carotid artery; IJV, Internal jugular alar fascia (anteriorly) and prevertebral fascia (posteriorly).
vein; M, Masseter muscle; MT, Medial pterygoid muscle; PP, These are the two layers of preverterbral layer of deep cervical
Parapharyngeal space; PT, Peritonsillar space; PV, Prevertebral fascia. It contains only loose connective tissue and extends
space; RP, Retropharyngeal space from skull base to mediastinum. So the infection of this space
can cause mediastinitis. During the surgical drainage, both
Lateral: Medial pterygoid muscle and mandible in ante- the dangerous and retropharyngeal spaces are treated as
rior part, and the deep surface of the parotid gland in one unit. A dissecting finger is used to disrupt the partition
the posterior part. between these two spaces.
540 Danger space: It lies between the alar fascia and the prevertebral Superior: Base of skull
space. Infection of this space can lead to mediastinitis and death Inferior: Lower border of mandible
Section 7 w neck if not properly treated. Lateral: Superficial layer of deep cervical fascia making
Prevertebral Space parotid capsule
It lies between the vertebral bodies and the prevertebral Medial: Muscles of mastication (masseter, medial and
fascia and extends from the skull base above to down up lateral pterygoids, and insertion of temporalis) and
to the coccyx. mandible.
Infection usually comes from the caries spine.
An abscess in the prevertebral space produces a midline SourceS of infectionS
bulge. No apparent source is found in good number of cases. The
sources, which have been encountered, include:
Submandibular Space (fig. 2) Tonsillitis is the most common cause of pediatric deep neck
Boundaries:
infections
The submandibular space lies between the mucous Poor dental hygiene is the most common cause in adults
membranes of floor of the mouth and tongue, and the Injection drug abuse
superficial layer of deep cervical fascia. Trauma
Iatrogenic: Surgical trauma
It extends between the hyoid bone and mandible. Esophageal perforation
Compartments Complications of mastoiditis: Bezold’s abscess and petrositis
Thyroiditis
Mylohyoid muscle divides this space into two compart- Pot’s cervical spine
ments. These compartments communicate with each other Laryngocele
around the posterior border of the mylohyoid muscle. Infected branchial and thyroglossal cysts.
Sublingual compartment: It lies above the mylohyoid.
Submaxillary and submental compartment: It lies below microbiology
They are often polymicrobial. The commonly encountered
the mylohyoid. species are the following:
Anaerobics comprise 90% of the bacteria in gingival crevice.
Space of body of mandible
Boundaries: It lies between the investing layer of deep Fusobacteria species
Pigmented bacteroides species
cervical fascia and body of the mandible. Investing layer Peptostreptococci species
of deep cervical fascia envelops the lower part of body Facultative anaerobic streptococci
of mandible and attaches to its periosteum. The space is Group A b-hemolytic streptococci pyogenes
limited anteriorly by the submental muscles and posteriorly Aerobic Gram-negative bacilli: In injection drug abusers and
by the masseter (external surface) and medial pterygoid seriously ill indoor patients
muscle (lingual surface). Staphylococci.
Communications: Infection can spread posteriorly to
masticator space and medially to submandibular space.
masticator Space clinicAl feAtureS
Boundaries and Extent The clinical features of deep neck infections include fever, chills,
decreased appetite, sore throat, painful swelling, referred otalgia,
trismus, dysphagia and respiratory distress.
fig. 2: submandibular space. coronal section showing inVeStigAtionS
pathway for pus
It is often difficult to differentiate between true abscess and
cellulitis or adenitis clinically.
CBC and serum electrolytes
Cultures: Throat swab, blood, sputum, needle aspirations of
possible abscess site.
Panorex oral view: For dental infections.
X-ray soft tissue neck lateral view: For assessing retropha-
ryngeal and pretracheal spaces. Normal thickness of
prevertebral soft tissue is 7 mm at axis (second cervical
vertebra) and 14 mm (children) or 22 mm (adults) at sixth
cervical vertebra.
X-ray chest: For assessing mediastinal silhouette for any
widening.
Ultrasonography: It is an easy, economical, safe and widely
available technology for seeing deep space neck abscesses.
It is used to guide needle aspiration and posttreatment Complete drainage of abscess including breaking of locula- 541
surveillance. tions.
CT and MRI: CT or MRI is often indicated. CT is usually the chapter 54 w deep neck infections
examination of choice though the MRI provides better Debride all devitalized tissue.
resolution for soft tissues and blood vessels. They can be
invaluable in defining: PeritonSillAr infectionS
Boundaries of infection Peritonsillar abscess (Quinsy) is a collection of pus in the peri-
tonsillar space which lies between tonsil capsule and the supe-
– Mass with air-fluid interface, cystic or multiloculated rior constrictor muscle covered by the buccopharyngeal fascia.
appearance
Source of infection
– Edema Tonsillitis is usually the source of infection. The crypta magna
– Contrast ring enhancement of tissue surrounding gets infected and sealed off. An intratonsillar abscess develops
which subsequently bursts through the tonsillar capsule into
the mass the peritonsillar space. The peritonsillitis sets up, and results in
Involvement of great vessels and internal jugular vein an abscess. It is a mixed infection of Streptococcus pyogenes,
Staphylococcus aureus, and anaerobic organisms.
thrombosis
Tracheal compression
Mediastinal spread.
The principles of managing deep neck abscesses are the clinical features
following: Clinical features include:
• Airway: Most patients need only humidified oxygen. Some Age: Most patients are adults. Children are rarely affected.
patients need a secure airway in the form of intubation. In Acute tonsillitis is more common in children.
some patients with respiratory distress, trismus and soft Side: Usually, it is unilateral.
tissue swelling make the intubation difficult and they need Local features: They are–
tracheostomy or cricothyrotomy.
• Ultrasound or CT-guided aspiration Pain: Unilateral severe throat pain.
• Fluid resuscitation Ipsilateral referred otalgia: Cranial nerve (CN) IX supplies
• Antibiotic therapy
• surgical drainage. tonsil, as well as ear.
Odynophagia may lead to drooling of saliva from the
treAtment
angle of mouth and dehydration.
Antibiotic therapy Hot potato voice: Muffled and thick speech.
It is not necessary to give antibiotics directed against all the Halitosis: Foul breath due to oral sepsis and poor hygiene.
cultured organisms because they are not equally pathogenic. Trismus: Due to spasm of pterygoid muscles which are
Many fastidious organisms are difficult to culture. Usually, anti-
biotics which are effective against streptococci, anaerobes and near to superior constrictor muscle.
b-lactamase-producing bacteria are used, and they include the General: The general features due to septicemia, which is
following:
Ampicillin-sulbactam or cefoxitin or ceftriaxone. usually present in all deep space neck infections include:
Combination of clindamycin plus ciprofloxacin (to cover Fever (up to 104° F) with chills and rigors
General malaise, body pain and headache
Eikenella corrodens, a Gram-negative facultative anaerobe Nausea and constipation.
and Pseudomonas aeruginosa) for penicillin allergic patients. Physical findings: They show
Combination of trimethoprim-sulfamethoxazole plus Anterior pillar and soft palate: Congestion and swelling
metronidazole.
Vancomycin is added if resistant Staphylococci are anterior and superior to the tonsil (Fig. 3).
suspected. Tonsil: Enlarged but gets buried in and hidden behind
Ticarcillin-clavulanate or piperacillin-tazobactam or
imipenem-cilastatin for compromised patients or suspected the edematous pillar and soft palate. Tonsillar exudate
Pseudomonas aeruginosa. may be seen.
Uvula: Swollen, edematous and pushed to the opposite
side.
Cervical lymphadenopathy of jugulodigastric lymph
nodes. Swelling is tender and painful.
Torticollis: Neck is tilted towards the side of the abscess.
Surgical drainage treatment
A. Medical
The principles of surgical drainage include:
Wide exposure and blunt dissection. The conservative measures which are taken in case of all
Identify the carotid sheath early to avoid damage. the deep-space neck infections, which may possibly cure
Pus or tissue specimen should be sent for: the patient, include:
Hospitalization.
Gram, acid-fast and fungal stains. Intravenous fluids to combat dehydration.
Culture of aerobic, anaerobic, and acid-fast bacteria Suitable antibiotics covering both aerobic and anaer-
and fungi obic organisms.
Tissue should be sent for pathologic evaluation.
542 Analgesics and antipyretics (paracetamol): Aspirin can Interval tonsillectomy: Tonsillectomy is done 4–6 weeks
increase the chances of bleeding and should not be after an attack of quinsy.
used.
Abscess or hot tonsillectomy: Abscess tonsillectomy
Oral hygiene: It is maintained by hydrogen peroxide or cuts down the cost remarkably. It avoids risk and
saline mouth washes. morbidity of second anesthesia and surgery and auto-
matically drains the abscess in the same sitting. The risk
B. Surgical of rupture of abscess during anesthesia and operative
Incision and drainage of abscess is indicated in cases of bleeding should be kept in mind.
frank abscess formation.
Method: With the help of a guarded knife, a small stab complications
incision is made at the point of maximum bulge above Though rare in this era of antibiotics, they include:
the upper pole of tonsil, or the junction of anterior pillar Parapharyngeal abscess may result in edema of larynx,
and base of uvula (Fig. 4). The site is usually touched
by phenol (carbolic acid) prior to incision. A sinus- or jugular vein thrombosis and spontaneous carotid artery or
artery-forcep is inserted to open and drain the abscess. jugular vein bleeding.
It may need to be repeated the following day to drain Airway obstruction may need tracheostomy.
any reaccumulation. Septicemia may lead to endocarditis, nephritis or brain
Peritonsillar (Quinsy) abscess forceps can also be used abscess.
for drainage of peritonsillar abscess. For further details Aspiration of pus (spontaneous rupture of abscess) may
of these forceps, see chapter “Instruments.” cause pneumonitis or lung abscess.
Section 7 w neck PArAPhAryngeAl SPAce AbSceSS or
PhAryngomAxillAry AbSceSS or
lAterAl PhAryngeAl SPAce AbSceSS
fig. 3: Peritonsillar abscess right side. swelling and congestion Sources of infections
of right anterior tonsillar pillar and soft palate. Tonsil gets buried in
and hidden behind the edematous pillar and soft palate Infection of parapharyngeal abscess can occur from:
Oropharynx: Bursting of peritonsillar abscess, pharyngitis,
fig. 4: Peritonsillar abscess. site of incision and drainage lies
just lateral to the junction of vertical anterior faucial pillar line and tonsillitis and adenoiditis
horizontal base of uvula line Dental: Infections of usually lower last molars.
Suppurative otitis media complications: Bezold’s abscess
and petrositis.
Extensions: Infections of parotid, retropharyngeal and
submaxillary spaces.
Injuries: Penetrating injuries of neck.
Iatrogenic: Injection local anesthetic for tonsillectomy or
mandibular nerve block.
clinical features
Common features: The patients with parapharyngeal
abscess usually present with
Fever
Odynophagia
Sore throat
Torticollis (due to spasm of prevertebral muscles)
Toxemia.
Other features depend upon the compartment involved.
They include the following:
Anterior compartment:
Prolapse of tonsil and tonsillar fossa
Trismus due to spasm of medial pterygoid muscle
Swelling behind the angle of jaw
Odynophagia.
Posterior compartment:
Pharyngeal bulging behind the posterior pillar.
Cranial nerve palsies: CN 9, 10, 11 and 12 palsies will
present with dysphagia and hoarseness of voice, and
ipsilateral nasal regurgitation and ipsilateral palsies of
palate, larynx and tongue.
Horner’s syndrome due to the involvement of sympa- 543
thetic chain. The syndrome consists of ipsilateral:
– Anhidrosis
– Partial ptosis
– Enophthalmos
– Constricted pupil
Swelling in parotid region.
complications
Airway obstruction due to edema of larynx.
Thrombophlebitis of jugular vein.
Retropharyngeal abscess.
Infection of mediastinum and carotid sheath.
Carotid artery bleeding.
treatment fig. 5: CT scan neck axial section. Retropharyngeal abscess chapter 54 w deep neck infections
Medical: Intravenous antibiotics to combat infection. Courtesy: Dr swati shah, Professor, Radio-diagnosis, GCR
Surgical drainage under general anesthesia: Preoperative Medical College, Ahmedabad.
tracheostomy is required in cases of marked trismus or head-low position. A vertical incision is made in the most
airway obstruction. A horizontal incision is made 2–3 cm fluctuant area of the abscess on the lateral part of the poste-
below the angle of mandible. Abscess is approached and rior pharyngeal wall. Suction must be ready and handy to
drained with blunt dissection along the inner surface of prevent aspiration of pus.
medial pterygoid muscle towards styloid process. A drain Tracheostomy: In cases of a large abscess causing airway
is usually inserted. Transoral drainage has the danger of obstruction and laryngeal edema.
injuring great vessels, and is avoided.
Acute retroPhAryngeAl AbSceSS chronic retroPhAryngeAl AbSceSS or
Most patients are children below 3 years of age. PreVertebrAl SPAce AbSceSS
It is common in adults and rare in children below 3 years of age.
Sources of infection
Suppuration of retropharyngeal lymph nodes occur secondary Sources of infection
to: The tubercular infection of prevertebral space can occur due to:
Infection in the adenoids, nasopharynx, posterior nasal Caries of cervical spine (Pot’s spine): It presents swelling in the
sinuses or nasal cavity. midline of posterior pharyngeal wall because the infection
Penetrating injury of posterior pharyngeal wall or cervical is behind the prevertebral fascia.
Tuberculosis of retropharyngeal lymph nodes: It occurs due
esophagus. to tuberculosis of the deep cervical nodes. It presents
Petrositis due to acute mastoiditis. swelling on the side of the midline as the infection is in the
retropharyngeal space.
clinical features
Dysphagia and airway obstruction (stridor) are prominent clinical features
Mild discomfort in throat and dysphagia.
symptoms because abscess obstructs the air and food Posterior pharyngeal wall: Fluctuant swelling centrally or
passages.
Croupy cough may be present. on one side of midline.
Torticollis: Stiff neck and extended head. Cervical tuberculous lymph nodes.
Unilateral bulging in posterior pharyngeal wall on one side
of the midline. diagnosis
X-ray cervical spines: Shows caries of the cervical spine.
diagnosis
X-ray soft tissue neck lateral view: Shows widening of prever- treatment
Medical: Full course of antitubercular therapy
tebral space and presence of gas. Incision and drainage of abscess: A vertical incision is made
CT scan: Figure 5 shows CT scan neck axial section of retro-
along the anterior border (for low abscess) or posterior
pharyngeal abscess. border (for high abscess) of sternocleidomastoid muscle.
treatment ludwig’S AnginA
Medical: Systemic intravenous antibiotics. It is the infection of the submandibular space.
Incision and drainage of abscess: Rupture of abscess may
occur during intubation. Child is kept in supine and
544 bacteriology External approach is needed if swelling involves
Infections involve both aerobes and anaerobes. submaxillary space.
Section 7 w neck The most common causative microorganisms are a – Method: A transverse incision extending between
angles of mandible, is made. The vertical opening
Hemolytic streptococci, staphylococci and bacteroides of midline musculature of tongue is made with the
groups. help of hemostat. Usually, it is serous fluid and not
Rarely Haemophilus influenzae, Escherichia coli and frank pus. It provides significant relief to the patient.
Pseudomonas are noted.
Tracheostomy must be considered if the airway is compro-
Sources of infection mised.
Dental infections account for 80% of the cases. Roots of
complications
lower premolars lie above the mylohyoid line and cause Spread of infection: The infection can spread to parapha-
sublingual space infection whereas roots of lower molar
teeth extend below the mylohyoid line and cause submaxil- ryngeal and retropharyngeal spaces and then to the
lary space infection. mediastinum.
Others: Submandibular sialadenitis, injuries of oral mucosa Airway obstruction: Airway is compromised not only due
and fractures of the mandible. to laryngeal edema but also due to swelling and pushing
back of the tongue.
clinical features Septicemia and aspiration pneumonia need immediate
Presenting complaints are marked difficulty in swallowing, attention.
odynophagia and varying degrees of trismus. AbSceSS of SPAce of body of
There occurs swelling in the floor of mouth. The tongue is mAndible
Sources of infection: Infection (such as periapical abscess) of
pushed up and back if the infection happens to be involving
the sublingual space. bicuspids and first and second molars of lower jaw.
Once the infection spreads to the submaxillary and Clinical features: Patient presents with a painful tender
submental spaces, the submandibular regions become
swollen and tender (Fig. 6), and feel woody hard. There swelling on the facial or/and lingual surface of the lower
is marked cellulitis of these areas. The frank abscess is part of the body of mandible (Figs 7A and B). Redness of
uncommon. surrounding gingiva may be seen in some patients. The
In advanced cases, airway is threatened. Tongue is progres- affected tooth feels long and becomes tender. Tenderness
sively pushed upwards and backwards. Laryngeal edema can be elicited in buccal or/and lingual sulcus where the
may ensue. abscess gets localized.
Treatment: It consists of antibiotics and surgical drainage.
treatment Depending upon where the abscess is pointing, hori-
Systemic antibiotics and incision and drainage are the main zontal intraoral incision is made on either buccal or lingual
surface. In some cases, it may also be drained externally by
lines of management. Drainage material must be submitted horizontal incision below and parallel to inferior border of
for culture and sensitivity. the mandible. The incisions should be carried through the
Incision and drainage: periosteum. The offending tooth needs either removal or
Intraoral approach is used when abscess is localized to root canal treatment.
Complications: Infection can spread posteriorly (common) to
sublingual space. masticator space and medially (uncommon) submandibular
space. Osteomyelitis is also common complication.
fig. 6: Ludwig’s angina. submental and submandibular mASticAtor SPAce AbSceSS
tender swelling in a 20-year old lady In comparison to parapharyngeal abscess patient is not acutely ill.
Sources of infections
Pericoronitis or impacted third molars
Posterior spread of infection of body of mandible space
clinical features
Severe painful swelling (Fig. 8): It extends over ramus of
mandible and obliterates subangular depression.
Fluctuation is usually absent.
Marked trismus (Fig. 9): It results from irritation of masseter
and medical pterygoid muscle.
Dysphagia.
Induration of posterior sublingual tissue making the tongue
depression difficult.
545
A chapter 54 w deep neck infections
fig. 9: Trismus in patient with masticator space abscess (pa-
tient of Fig. 8)
treatment
Parenteral antibiotics for 1 week
Incision and drainage:
External incision: In infections not resolving with anti-
biotics, an external incision is made below and behind
the angle of mandible. Blunt dissection is carried up to
the subperiosteal abscess.
Intraoral incision: When abscess points lingually, vertical
incision along the anterior border of ramus is made.
Blunt dissection is carried on both medial and lateral
to ramus of mandible.
b complications
Buccinator space infection – more common
figs 7A and b: (A) Abscess of space of mandible. swelling of Osteomyelitis of mandible
lower part of the body of mandible. Note mental region is not Temporal space infection
involved. swelling in the submandibular region indicates that in- Parotid space infection – occasional on superficial rupture
fection is spreading to the submandibular space; (B) Abscess of Parapharyngeal space infection – rare.
space of mandible. swelling on the lingual surface of the lower
part of the body of mandible. swelling in the sublingual region triSmuS
indicates that infection is spreading to the submandibular space (L. fr. G. trismos, a creaking, rasping; Synonym: Lockjaw)
Persistent contraction of masseter muscle leads to inability to
open the mouth. In the past, tetanus was a common cause but
in India now, perhaps the most common cause is oral submu-
cous fibrosis.
fig. 8: Masticator space abscess. Tender red swelling extending causes
over ramus of mandible and obliterating subangular depression They can be divided into three groups: acute painless, acute
painful, and chronic.
1. Acute Painless Trismus
a. Tetanus: Spasms of neck and abdominal muscles.
Convulsions occur due to the painful tonic muscular
contractions.
b. Tetany: It occurs due to calcium deficiency and hypo-
parathyroidism. It is characterized by muscle twitches,
cramps and carpopedal spasm, severe laryngospasm
and seizures.
c. Strychnine poisoning: It stimulates all parts of the
central nervous system. The muscles are relaxed in
between the convulsions.
546 2. Acute Painful Trismus 3. Chronic Trismus
a. Peritonsillar abscess: Trismus occurs due to the spasm a. Oral submucous fibrosis: Whitish fibrous bands in buccal
of pterygoid muscles. Drooling of saliva (due to odyno- and palatal region and history of chewing Paan,Sopariand
phagia), fever, congestion and fullness in peritonsillar Tobacco will confirm the diagnosis.
region will confirm the diagnosis. b. Ankylosis of temporomandibular joint.
b. Parapharyngeal abscess of anterior compartment: Torti- c. Malignancy of buccal mucosa, tonsil, retromolar
collis (due to spasm of prevertebral muscles), prolapse trigone, pterygopalatine fossa, maxillary sinus, and
of tonsil and tonsillar fossa, trismus (due to spasm of parotid: These malignant tumors are visible on exami-
medial pterygoid muscle) swelling behind the angle of nation.
jaw, and odynophagia will confirm the diagnosis.
c. Ludwig’s angina: Painful swelling in the floor of mouth Sequela
and submandibular region can be seen. Poor oral hygiene.
d. Alveolar infection especially of last molar region. Difficulty in enjoying sumptuous meals.
e Acute parotitis: Mumps and bacterial parotitis, and abscess. Difficulty in examination of oral cavity pharynx, and larynx.
f. Acute temporomandibular arthritis. Endotracheal intubation: In cases of emergency and anes-
g Condylar fracture of mandible: History of trauma and
painful swelling. OPG will confirm the diagnosis. thesia, endotracheal intubation becomes troublesome, and
h. Acute otitis externa especially furuncle. patient may need tracheostomy.
Section 7 w neck clinical highlights
1. ct with contrast enhancement: It is the most valuable investigation in deep neck infections.
2. Peritonsillar abscess (Quinsy): There occurs collection of pus in the peritonsillar space, which lies medial to superior
constrictor muscle of pharynx. Trismus is due to spasm of medial pterygoid muscle.
3. Parapharyngeal abscess: The parapharyngeal abscess collects medial to medial pterygoid muscle. The otogenic
parapharyngeal abscess is caused by petrositis. In other instances it occurs due to caries/extraction of molar tooth. Patient
develops trismus, fever and swelling that pushes the tonsil medially and spreads laterally posterior to sternocleidomastoid.
4. ludwig’s angina: The spaces involved in Ludwig’s angina are sublingual, submental and submandibular.
further reAding
1. Bora MK, Narwani S, Mishra P, et al. A bullet in the parapharyngeal space. Indian J Otolaryngol Head Neck Surg. 2002;54:46-7.
2. Ghumbre RU, Nitnaware AZ. A sterile acute retropharyngeal abscess. Indian J Otolaryngol Head Neck Surg. 2005;57:152-4.
3. Gupta A, Kawade R, Gupta V. Traumatic retropharyngeal abscess presenting with quadriparesis: A case report. Indian J Otolaryngol
Head Neck Surg. 2000;52:264-6.
4. Gupta N, Varshney S, Bist SS, et al. Retropharyngeal abscesses: Revisited. Indian J Otolaryngol Head Neck Surg. 2007;59:309-12.
5. Kaluskar S, Bajaj P, Bane P. Deep space infections of neck. Indian J Otolaryngol Head Neck Surg. 2007;59:45-8.
6. Kamath MP, Shetty AB, Hedge MC, et al. Presentation and management of deep neck space abscess. Indian J Otolaryngol Head Neck
Surg. 2003;55:270-5.
7. Ravikumar A, Ezhilarasu P. Profile of neck cellulitis—clinician’s dilemma. Indian J Otolaryngol Head Neck Surg. 2005;57:330-2.
8. Verghese A, Chaturvedi VN, Singh AKK, et al. Peritonsillar abscess—a clinico bacteriological study. Indian J Otolaryngol Head Neck Surg.
2001;53:112-5.
Section 8 : Operative Procedures and Instruments
55 Middle Ear and
Mastoid Surgeries
To succeed, you must have tremendous perseverance, tremendous will. ‘I will drink the ocean,’
says the persevering soul, ‘at my will, mountains will crumble up’. Have that sort of energy,
that sort of will; work hard, and you will reach the goal.
—Swami Vivekananda
points of focus
¯ MyringotoMy and tyMpanoStoMy tubeS Postoperative Care
Indications for Myringotomy Complications
Indications for Grommet ¯ radical MaStoidectoMy
Preoperative Evaluation Indications
Anesthesia Steps of operation
Types of Tympanostomy Tubes Postoperative Care
Technique Complications
Postoperative Care ¯ Modified radical MaStoidectoMy
Complications Indications
Indications for Removal of Retained Tympanostomy Tube operation
Bondy Procedure
¯ MaStoidectoMy ¯ tyMpanoplaSty
Types Types of Tympanoplasty
Surgical Approaches: Endaural, Postaural, Endomeatal Myringoplasty
Anesthesia ossiculoplasty
Position of Patient ¯ clinical HigHligHtS
¯ cortical MaStoidectoMy
Indications
Instruments
Steps of operation
MyringotoMy and tyMpanoStoMy tubeS Myringotomy/grommet insertion are not done in suspected
(groMMet) cases of intratympanic glomus tumor because these procedures
Myringotomy refers to an incision of the tympanic membrane can cause profuse bleeding in such patients.
to drain middle ear fluid, which may be suppurative or nonsup-
purative (Fig. 1). indications for Myringotomy
Indications in acute otitis media (AOM)
Ventilation tube (grommet) is inserted through myrin-
gotomy incision for draining middle ear fluid as well as for Bulging eardrum
providing aeration in case of malfunctioning Eustachian tube. Acute excruciating pain
548 Unresponsive to antibiotics: Incomplete resolution with anesthesia
opaque drum and persistent conductive deafness General anesthesia
Section 8 w operative procedures and instruments
Complications: Facial paralysis, labyrinthitis or menin- In children and uncooperative adults
gitis with bulging tympanic membrane. Acutely inflamed tympanic membrane.
Local anesthesia: In cooperative adults.
Otitis media with effusion (OME). Topical anesthesia
Aero-otitis media to drain middle ear fluid and“unlock”the Phenol
Topical tetracaine-base powder suspended in alcohol
Eustachian tube. Lidocaine delivered with iontophoresis
Atelectatic ear: Grommet is often inserted for long-term Eutectic mixture of lidocaine and prilocaine.
aeration. types of tympanostomy tubes (figs 2a to d)
1. Titanium tympanostomy tubes
Short-term tympanostomy tubes (grommet) provide longer 2. Silveroxide tympanostomy tubes
lasting drainage of middle ear effusion than myringotomy. 3. Small-flanged grommet tubes such as Donaldson tube.
4. Short-flanged T-tube of soft silicone.
indications for grommet
Recurrent AOM. technique
Chronic secretory or otitis media with effusion (COME). Requirement: The procedure is always done under operating
Barotitis media.
Tympanic membrane abnormalities microscope. Clean wax and debris from external auditory
canal (EAC).
Severe retraction Site, size and shape of incision: Perform myringotomy in ante-
Atelectasis rior portion preferably anteroinferior quadrant of tympanic
Retraction pocket with impending membrane using a sharp myringotome. Myringotomy may
be done by a fine knife used in ear microsurgery. Either
– Ossicular chain erosion radial or circumferential incision are employed.
– Cholesteatoma. Acute otitis media: A circumferential incision in the
Eustachian tube dysfunction.
Cleft palate with long-standing OME and hearing loss posteroinferior quadrant of pars tensa avoids injury to
AOM with mastoiditis, facial palsy and intracranial compli- incudostapedial joint.
cations. Otitis media with effusion: A small radial incision may be
Hyperbaric oxygen therapy: For the prevention of middle used in the posteroinferior or anteroinferior quadrant
ear complications such as severe ear pain, hemotympanum of pars tensa.
and OME. Grommet: The size of incision should be just enough to
admit the grommet.
The common indications for grommet are recurrent AoM and Cautions: Following precautions should be taken:
chronic oME.
preoperative evaluation
History and physical examination
Audiometry
Tympanometry
a bc
d
fig. 1: Myringotomy incisions. Circumferential (C) for acute sup- figs 2a to d: Ventilation tubes. (A) Tuebingen ventilation tube;
purative otitis media (ASoM) and radial (R) for otitis media with (B) Sheehy teflon ventilation tube; (C) Shepard teflon ventilation
effusion (oME) tube with wire; and (D) Grommet in position for middle ear ven-
tilation
Thick tympanic membrane: A deep incision that cuts 1. Postaural (or Wilde’s) incision (Fig. 4A): This postaural incision 549
through entire thickness of tympanic membrane is begins at the highest attachment of the pinna and ends at
required. the mastoid tip. The incision may lie either 1 cm behind or chapter 55 w Middle ear and Mastoid Surgeries
in the retroauricular groove. In infants and children up to 2
Acute otitis media: In cases of acute inflammation years of age, the postaural incision must be slanting poste-
distinction between the tympanic membrane and riorly to avoid lower part of the mastoid. In these children
posterior meatal wall is lost. Avoid putting incision in the mastoid process is not developed and stylomastoid
the posterior meatal wall. foramen from where facial nerve emerges is located more
superficially. The slanting incision avoids cutting facial nerve
postoperative care which is superficial.
Topical antibiotic ear drops in presence of mucoid effusion Indications: The postaural incision is preferred by many
for:
reduce otorrhea. – Cortical mastoidectomy
Swimming: Surprisingly, studies found no difference in rates – Modified radical and radical mastoidectomy
– Tympanoplasty
of otorrhea in patients who swam or not with or without – Decompression of facial nerve
earplugs. – Endolymphatic sac operation.
Hearing tests.
Follow-up: Twice year otoscopy/microscopy to assess 2. Endaural approach (Fig. 4B): Lempert’s incision employed
Status of tympanostomy tube for the endaural approach has two parts.
Tympanic membrane for perforation, retraction pocket, a. Lempert I: This semicircular horizontal incision is made
at the bony cartilaginous junction in the posterior
atelectasis and cholesteatoma. meatal wall. The incision extends from 12 O’clock to 6
O’clock position.
complications b. Lempert II: This curvilinear vertical incision begins
Complications are uncommon in experienced hands. The from the 1st incision at 12 O’clock and passes upwards
potential morbidities are following: between tragus and the crus of helix (incisura terminalis)
Otorrhea: Most common. without cutting the aural cartilage.
Myringosclerosis: It is of little functional importance.
Trauma: External auditory canal lacerations and injury to box 1: Types of mastoidectomies
1. Simple mastoidectomy (cortical mastoidectomy or Schwartz
ossicles such as incudostapedial joint or stapes
If jugular bulb is high and floor of the middle ear dehis- operation)
2. Canal wall-up procedures (intact posterior meatal wall or
cent, injury to jugular bulb can cause profuse bleeding.
Tympanic membrane: closed procedures)
a. With facial recess approach
Perforation b. Without facial recess approach
Atrophy 3. Canal wall-down procedures (open procedures)
Retraction a. Radical mastoidectomy
Atelectasis b. Modified radical mastoidectomy
Cholesteatoma. c. Bondy procedure
Grommet: 4. Tympanoplasty (reconstructive surgery)
Migration or loss of tube into middle ear a. During the primary surgery
Early extrusion b. Second stage
Plugging of tube.
Anesthetic complications.
indications for removal of retained
tympanostomy tube
Chronic otorrhea.
Granuloma formation.
Blockage of tube.
Migration of tube into middle ear.
MaStoidectoMy fig. 3: Postaural and endaural approaches to mastoid antrum
Mastoidectomy is an operation in which mastoid antrum is
opened and air cells are removed. This operation can be done
either alone or in association with tympanoplasty, which consists
of eradication of middle ear disease and reconstruction of the
hearing mechanism. The various types of mastoidectomies are
enumerated in Box 1.
Surgical approaches
Depending upon the surgeon and nature and extent of the
lesion middle ear and mastoid operations can be done with
two approaches endaural and postaural (Figs 3 and 4A to C).
550 Indications: Both mastoid and external canal surgeries position of patient
can be done. It is preferred for the following conditions: Patient lies in supine position with head turned to the side so
Section 8 w operative procedures and instruments – Osteoma and exostosis of EAC that operation ear is on upper side.
– Large tympanic membrane perforation
– Atticoantrotomy: Atticoantral cholesteatoma cortical MaStoidectoMy
– Modified radical mastoidectomy: Cholesteatoma of (Synonyms: Simple or Complete Mastoidectomy or Schwartz
attic, antrum and mastoid. Operation)
Cortical mastoidectomy refers to complete exenteration of all
3. Endomeatal or transcanal approach (Fig. 4C): Rosen’s stape- accessible mastoid air cells without removing the posterior
dectomy incision is an example of endomeatal incision. A meatal wall. Middle ear structures are not disturbed.
posterior tympanomeatal flap is raised to enter into the
middle ear. Posterior meatal wall skin is raised and annulus indications
dislocated from the sulcus. The posterosuperior overhang Acute coalescent mastoiditis with or without subperiosteal
of bony meatus if hiding the view of stapes is removed.
Rosen’s incision consists of two parts: abscess.
a. I incision: A small vertical incision begins at 12 O’clock Incompletely resolved AOM with reservoir sign.
position near the annulus. Masked mastoiditis.
b. II incision: A curvilinear incision 5–7 mm away from the Primary step to perform:
annulus begins at 6 O’clock position and meets the 1st
incision in the posterosuperior region of deep bony canals. Cochlear implantation.
– Indications: It offers nice view of the middle ear and Endolymphatic sac surgery.
ossicles. The indications include: Decompression of facial nerve.
- Exploratory tympanotomy Labyrinthectomy.
- Stapedectomy Cerebrospinal fluid (CSF) otorrhea.
- Inlay myringoplasty Access to cerebellopontine angle (acoustic neuroma),
- Ossicular reconstruction.
skull base, and petrous apex (translabyrinthine or retro-
labyrinthine procedures).
anesthesia instruments (figs 5a to i and 6a to o)
The surgery is usually done under general anesthesia. Some See also Chapter Instruments.
surgeons prefer local anesthesia in selected cases.
Steps of operation
a 1. Incision: A postaural incision cuts through soft tissues and
b reaches up to the periosteum without cutting the tempo-
ralis muscle. Mastoid retractors (Jansen’s or Mollison’s)
c retract soft tissues after the postaural incision and elevation
figs 4a to c: Surgical approaches. (A) Postaural incisions (S, of flaps. The pressure on the edges of the incision provides
Sulcus; R, Retrosulcus; and I, Infants); (B) Endaural incision hemostasis. Lempert’s endaural retractor is used in cases of
(I, Lempert I posterior meatal wall semicircular incision 6 to 12 endaural approach. Lempert’s endaural speculum can be
o’clock; and II, Lempert II upward curvilinear 12 o’clock incision used to spread open the meatus when giving local injection
in the incisura terminalis of cartilaginous EAC); and (C) Endo- or making an endaural incision.
meatal incision (Rosen) 2. Exposure of Mastoid: Periosteum is cut in the line of postaural
incision. A horizontal incision is made along the lower border
of temporalis muscle. A branch of superficial temporal artery
is usually encountered and may need ligation or cauteri-
zation. Periosteum is elevated from the lateral surface
of mastoid and posterosuperior region of bony meatus.
Farabeuf’s periosteal elevator may be used for elevation of
periosteum from the mastoid cortex. Tendinous fibers of
sternocleidomastoid muscle need sharp cutting near the
mastoid tip. A self-retaining mastoid retractor is applied
for the exposure.
3. Identification of mastoid antrum: Mastoid cortex is drilled
out to enter into the mastoid antrum. In adults mastoid
antrum lies 12–15 mm deep to the suprameatal triangle
(Macewen’s triangle, Fig. 7). Mastoid gouges may be used to
remove mastoid bone. Horizontal semicircular canal, aditus
ad antrum and short process of incus are identified. Mastoid
suction tips helps aspirating blood, discharge, irrigation
water and bone dust and pieces.
4. Removal of mastoid air cells: Lempert’s mastoid curette (scoop)
removes bony septa and granulations in mastoid antrum
551
fig. 7: Macewen’s triangle. Surface landmark for mastoid chapter 55 w Middle ear and Mastoid Surgeries
antrum
figs 5a to i: Mastoidectomy instruments. (A) Farabeuf’s cutting
edge curved raspatory; (B) Elevator and raspatory (curved with
straight tip); (C) Gauges; (D) Hammer; (E) Straight slip joint hand
piece for burrs; (F) Burrs (G) Suction cannula and adaptor with
finger cut-off; (H) Mastoid retractor with 3×4 prongs; and (I) Mas-
toid retractor 3×3 prongs
fig. 8: Simple cortical mastoidectomy with intact posterior
meatal wall
figs 6a to o: Ear microsurgery instruments. Micro ear forceps fig. 9: Cortical mastoidectomy cavity—landmarks and struc-
tures seen
are with tubular shafts. Their opening and closing of the jaw are
c. Trautmann’s triangle: This bony plate of posterior surface
by means of thumb ring-handle. (A) Ear speculum for adults, of petrous bone lies behind the mastoid antrum. It is
black finish in- and outside to eliminate reflection; (B) Straight bounded by following structures:
needle perforator (for footplate); (C) Round cutting knife angled – Sigmoid sinus
– Bony labyrinth
90° for incising skin of external auditory canal; (D) Sickle knife – Superior petrosal sinus.
slightly curved; (E) Teflon piston holding straight alligator forceps;
(F) Double ended round cutting flap knife (blade in line with shaft) d. Donaldson’s line: This line passes through the lateral
and angled (45°) round cutting knife; (G) Straight sharp micro semicircular canal bisecting the posterior semicircular
canal. The endolymphatic sac that appears as thickening
scissors with tubular shaft; (H) Ear curette; (I) Straight alliga- of the posterior cranial fossa dura (double layered) is
situated inferior to Donaldson’s line.
tor forceps; (J) Buttoned ear hook; (K) Sharp point curved nee-
dle (pick); (L) Upward cutting malleus nipper; (M) Teflon piston
measuring rod; (N) Sharp point straight needle (pick); and (o)
Measuring rod (caliper) marker pins at 3.5, 4 and 4.5 mm
and air cells. The electrical drill and burs are replacing the
use of gouges and curettes. All the accessible mastoid air
cells are removed. Zygomatic cells in the root of zygoma and
retrosinus cells behind the sinus between sinus plate and
cortex are also removed. The bony plate of tegmen tympani
above, sinus plate behind and posterior meatal wall in front
though exposed are not removed (Figs 8 and 9).Try to identify
following structures in the newly created mastoid cavity:
a. Sinodural angle: It lies between the tegmen antri (middle
cranial fossa) and the sigmoid sinus.
b. Solid angle: This solid bone angle, which lies medial to
antrum, is formed by the three semicircular canals.
552 5. Removal of mastoid tip: Removal of the lateral wall of
mastoid tip will expose muscle fibers of posterior belly of
digastric. Edges of the mastoid cavity should be beveled
(saucerization of edges) so that soft tissue sits in and oblit-
erates the cavity.
6. Closure of wound: After cleaning the bone dust from the
wound and mastoid cavity (thorough irrigation with saline),
the wound is closed in two layers. If there is infection or
excessive bleeding, a rubber drain may be kept at the lower
end of incision for 1 to 2 days. The EAC is packed with ribbon
gauze impregnated in antimicrobial agent. It avoids stenosis
of ear canal. Mastoid bandage is applied.
Section 8 w operative procedures and instruments postoperative care fig. 10: Radical mastoidectomy cavity after removing the pos-
Antibiotics: They are started before the surgery and
terior meatal wall, exteriorizing the area of mastoid, middle ear,
continued postoperatively for at least 1 week. Perioperative
swab for culture from the mastoid helps in identifying the attic and antrum, removing malleus and incus and obliterating
microorganisms and selecting the antibiotic.
Mastoid drain: It is usually removed in 1–2 days. the Eustachian tube
Removal of stitches: They are removed usually on the 6th
day. Steps of operation (See Steps of cortical
complications Mastoidectomy)
Perioperative injuries to:
1. Incision: Postaural or endaural.
Facial nerve 2. Exposure of mastoid area: The periosteum from the lateral
Horizontal semicircular canal: Patient develops vertigo
mastoid surface is elevated. This extends from the root
and jerky nystagmus of zygoma to the area behind the suprameatal triangle
Sigmoid sinus (profuse bleeding) and from suprameatal crest (continuation of inferior
Dura mater of middle cranial fossa-CSF leak temporal line) to the lower part of mastoid tip. The wound
Dislocation of incus-conductive hearing loss is retracted.
Postoperative 3. Exposure of attic and antrum: The cortical mastoid bone is
Wound infection and wound break-down. drilled out from the suprameatal triangle, spine of Henle,
root of zygoma and upper part of superior meatal wall till the
radical MaStoidectoMy exposure of attic and antrum. The tegmen antri and lateral
Radical mastoidectomy eradicates disease from the middle ear semicircular canal are identified.
and mastoid and exteriorizes mastoid, middle ear, attic and 4. Removal of “bridge” and facial buttresses: Deeper part of
antrum into the external ear by removing the posterior meatal superior bony meatal wall bridging over the notch of Rivinus
wall (Fig. 10). The structures removed include cholesteatoma, is taken off carefully without damaging the deeper middle
granulations and remnants of tympanic membrane, malleus, ear structures. The removal of anterior buttress (anterior
incus (not the stapes) chorda tympani and mucoperiosteal spine of the notch) and posterior buttress (posterior spine of
lining. The opening of Eustachian tube is closed with a piece the notch), which form the lateral attic wall, will expose the
of muscle or cartilage. regions of attic, aditus ad antrum, facial canal and ossicles.
The diseased incus and the malleus are removed.
There is no reconstruction of hearing system. As the poste- 5. Lowering of facial ridge: The deeper part of posterior
rior meatal wall is removed, the entire area of middle ear, attic, meatal wall lying over the vertical part of facial nerve
antrum and mastoid is converted into a single cavity. The called facial ridge is removed as much as possible within
basic aim is to exteriorize the diseased area for inspection and the safety of facial nerve. It makes mastoid cavity easily
cleaning. This radical surgery is infrequently required these days. inspected and cleaned during the postoperative care.
6. Debridement of middle ear: Remnants of tympanic
indications membrane, annulus and sulcus tympanicus, middle ear
CSOM with intracranial complications. mucoperiosteum, cholesteatoma, polyp and granulation
Cholesteatoma invading Eustachian tube, round window tissue, malleus and incus are removed step by step. Stapes
is left intact. Eustachian tube mucosa is curetted and
niche, perilabyrinthine or hypotympanic cells plugged with tensor tympani muscle or piece of cartilage.
Revision surgery to eradicate chronic inflammatory disease 7. Cavity inspection and irrigation: Ensure complete exteri-
orization of the mastoid antrum and cavity and middle
or remnant cholesteatoma ear including attic into the EAC. Bony overhangs are
Disease in petrous apex removed and cavity is smoothened with polishing burr.
Glomus tumor Saucerization of the cortical edges of mastoid must be
Carcinoma middle ear: If en bloc removal of temporal bone done. Irrigate the cavity and wound with saline or ringer
to remove blood and bone dust.
is not feasible then radical mastoidectomy followed by
radiotherapy may be considered.
8. Meatoplasty: A concha based flap from posterior and which are necessary to reconstruct hearing mechanism, are 553
superior meatal wall is raised and turned into the mastoid preserved.
cavity. It covers the area of the facial ridge and facilitates chapter 55 w Middle ear and Mastoid Surgeries
epithelialization of the mastoid cavity. In this operation, indications
which is invariably combined with canal wall-down proce- Atticoantral cholesteatoma.
dures, a crescent of conchal cartilage is excised to widen Chronic otitis media with limited disease.
the meatus. This meatoplasty facilitates access to cavity
for inspection and cleaning during the postoperative care. operation
Meatoplasty is also done as an isolated procedure in The operative steps, postoperative care and complications
cases of sagging auricle, which is seen in older people. are similar to radical mastoidectomy and the differences are
The obstruction of the ear canal causes hearing loss and following:
retention of wax. 1. Removal of disease and preservation of healthy tissue:
9. Mastoid obliteration: If the ultimate mastoid cavity Cholesteatoma, granulations and unhealthy mucosa are
becomes very large, it may be obliterated with temporalis removed. Incus and head of malleus are preserved. They
muscle or other musculofascial tissues. Due care must be are removed only if cholesteatoma engulfs them or extends
taken to remove any vestige of disease (cholesteatoma), medial to them. Healthy pars tensa and middle ear struc-
which may be buried underneath. tures are left undisturbed.
2. Tympanoplasty: Reconstruction of tympanic membrane and
10. Closure of wound: The mastoid cavity is packed with ossicular chain depending upon the extent of damage can
ribbon gauze, impregnated with an antibiotic/antiseptic be done (mastoidectomy with tympanoplasty operation)
solution. The wound is closed in two layers. Mastoid at the same sitting or in second stage.
bandage is applied.
bondy procedure
postoperative care The attic is exteriorized by removing portions of the adjacent
Antibiotic: It is given for 7–14 days. superior and/or posterior canal wall. The uninvolved middle ear
The bandage and packing: They are removed as per the liking is not entered. The cholesteatoma matrix on the lateral surface
of malleus head and incus body is maintained in place as a lining
of the surgeon from 1–7 days. Skin stitches are removed on for the created cavity.
6th or 7th day. Some prefer changing of the pack at weekly
intervals and others leave the cavity unpacked with regular tyMpanoplaSty
suction and cleaning till the epithelialization of the cavity. These surgeries are done under operating microscope with the
Look for any signs of perichondritis or infection. help of microsurgical instruments and biocompatible implant
Cavity care: The epithelialization of cavity takes 2–3 months. materials.
The cavity is checked every 4–6 months in the first year and Tympanoplasty: The tympanoplasty operation consists of
then annually. The debris is removed. Granulation tissue
which delays the healing is either removed or chemically both eradication of middle ear disease and reconstruction
cauterized. of hearing mechanism including tympanic membrane and
ossicles. It may be done with or without mastoidectomy.
complications Myringoplasty: The limited repair of tympanic membrane is
Perioperative injury to: called myringoplasty.
Ossiculoplasty: The limited reconstruction of ossicular chain
Facial nerve resulting in facial paralysis. is called ossiculoplasty.
Dura or sigmoid sinus.
Stapes dislocation can result in labyrinthitis sensori-
neural hearing loss (SNHL) and vertigo.
Severe conductive hearing loss due to removal of the
ossicles and tympanic membrane.
Perichondritis
Cavity problems:
Nonhealing of cavity.
Regular after care.
Modified radical MaStoidectoMy fig. 11: Modified radical mastoidectomy cavity after removing
In this modification of radical mastoidectomy, hearing mecha- the posterior meatal wall and exteriorizing the diseased area of
nism and middle ear cleft structures are preserved as far as attic and mastoid antrum without removing the normal ossicles
possible. Only irreversibly damaged tissues are removed. and tympanic membrane
Preservation and conservation of middle ear structures help
in reconstruction of the hearing mechanism.
Modified radical mastoidectomy eradicates disease from
the attic and mastoid and exteriorizes both into the EAC by
removal of the posterior meatal and lateral attic walls (Fig. 11).
The remnant of tympanic membrane, functioning ossicles and
the reversible mucosa and function of the Eustachian tube,
554 types of tympanoplasty (Wullstein) (figs 12a to graft material includes fascia lata, cartilage and homograft
(dura, vein, cadaver tympanic membrane).
Section 8 w operative procedures and instruments e) Techniques: There are following two techniques underlay
(inlay) and overlay (onlay).
Wullstein described five types of tympanoplasty (Table 1). Underlay technique: In this technique, graft is placed
Several modifications in the Wullstein classification have been
reported in the literature, which mainly pertain to the types of medial to the tympanic annulus.The underlay technique
ossicular reconstruction. requires opening of the middle ear (tympanotomy),
Cavum minor and tympanoplasty IV: In Type IV tympano- which provide an opportunity to examine the ossicles
and other middle ear structures.
plasty graft (Fig. 13) is placed between the oval and round Overlay technique (Figs 14A to C): In this technique, graft is
windows to create an air pocket around the round window. placed lateral to fibrous layer of the tympanic membrane.
This narrow middle ear space, which is called cavum minor, It requires careful removal of squamous epithelium from
is a mucosa-lined space that extends from the Eustachian the lateral surface of remnant tympanic membrane.
tube to the round window. Sound waves in this Type IV Inlay technique: Graft is placed in between the fibrous and
tympanoplasty directly hit on the footplate while the round mucosal layers of tympanic membrane.
window has been shielded by the cavum minor.
Tympanoplasty V: In Type V tympanoplasty a window is ossiculoplasty
created on horizontal semicircular canal that is covered
with a graft. Indications: Ossicular reconstruction is required in cases
of destruction of ossicular chain mostly caused by chronic
Myringoplasty suppurative otitis media (CSOM)
Destruction of ossicles
The simple closure of tympanic membrane perforation is called – Necrosis of long process of incus: It is the most
myringoplasty. common lesion.
Graft materials: The most commonly used graft materials
are temporalis fascia and tragal perichondrium. The other
ab
cd e
figs 12a to e: Types of tympanoplasty. (A) Tympanic membrane graft touches malleus (Type I); (B) Incus (Type II); (C) Stapes
superstructure (Type III); (D) Mobile stapes footplate (Type IV); and (E) Lateral semicircular duct (Type V) stapes fixed
table 1 Types of tympanoplasty (Wullstein)
Types Defect Position or contact of graft
Tympanic membrane or malleus
Type I (myringoplasty) Tympanic membrane perforation Incus or remnant of malleus
Type II Tympanic membrane perforation Stapes superstructure
with erosion of malleus
Stapes footplate
Type III Myringostapediopexy or columella Malleus and incus absent Fenestra in horizontal semicircular canal
tympanoplasty
Type IV Stapes superstructure absent
Type V Fenestration operation Stapes footplate fixed
555
a
fig. 13: Tympanoplasty IV. There is only acoustic coupling and b chapter 55 w Middle ear and Mastoid Surgeries
no ossicular coupling. Graft acoustically protects round window c
figs 14a to c: overlay myringoplasty. (A) Incision (I) to raise
while sound directly impinges stapes footplate the meatal skin (S) and epithelium of tympanic membrane; (B)
Placement of temporalis fascia (TF) graft; and (C) Replacement
– Loss of stapes superstructure: It leaves behind a of meatal skin and epithelium of tympanic membrane
mobile footplate and malleus.
– Total ossicular replacement prosthesis: A total ossic-
– Destruction of malleus, incus and the stapes super- ular replacement prosthesis (TORP) bridges the gap
structure: They leave behind only the mobile foot- between tympanic me mbrane and stapes footplate.
plate. It is common in cholesteatoma.
– Partial ossicular replacement prosthesis: A partial
Fixation of ossicles ossicular replacement prosthesis (PORP) provides
– Ankylosis of stapes footplate (otosclerosis and a direct contact between tympanic membrane and
tympanosclerosis): The correction of ankylosis of stapes head.
stapes consists of removal of the superstructures
stapes and its replacement by prosthesis.
– Fixation of the head of malleus in the attic (tympano-
sclerosis and congenital): The attic fixation of malleus
head needs removal of the head of malleus and entire
incus. Then a contact is established between handle
of malleus and the stapes.
Graft materials: They are:
Autografts (Figs 15A to D):The most commonly employed
graft materials are autograft ossicles (incus transposition
and sculptured ossicles) and tragal cartilage.
Homograft: Ossicles and membrane.
Prosthetic implants: They are made of ceramic (hydroxy
appetite) and teflon.
ab
cd
figs 15a to d: ossicular reconstruction. (A) Malleus-stapes assembly; (B) Malleus-footplate assembly; (C) Reshaped incus between
stapes head and tympanic membrane graft; and (D) Reshaped incus between stapes footplate and tympanic membrane graft
556 clinical Highlights
1. operative microscope: The objective piece of microscope commonly used for ear microsurgery is 200–300 mm (250
mm).
2. Mastoid surgery: Aim of mastoid surgery in unsafe chronic suppurative otitis media (CSoM) is rendering the ear safe.
Techniques, which are used to control bleeding from bone during mastoid surgery, include bone wax, bipolar cautery over
the bleeding area and diamond drill. Cutting drill over the bleeding area will not control bleeding.
3. radical mastoidectomy: Eustachian tube is obliterated surgically in radical mastoidectomy. Closure of Eustachian tube
prevents infection of middle ear from the nasopharynx.
4. grafts: Autograft tympanic membrane acts as a scaffold. Denatured homograft tympanic membrane has no antigenic
property.
Section 8 w operative procedures and instruments furtHer reading
1. Agrawal A, Baisakhiya N, Deshmukh PT. Combined Middle Cranial Fossa and Transmastoid Approach for the Management of Post
mastoidectomy CSF Otorrhoea. India J Otolaryngol Head Neck Surg. 2011;63:S142-6.
2. Ahmad R, Ali I, Naikoo GM, et al. Giant Mastoid Emissary Vein: Source of Profuse Bleeding During Mastoid Surgery. India J Otolar-
yngol Head Neck Surg. 2011;63:S102-3.
3. Albert RRA, Job A. Cyanoacrylate in myringoplasty—An office based procedure. Indian J Otolaryngol Head Neck Surg. 2004;56:133-5.
4. Anand TS, Kahuria G, Kumar S, et al. Butterfly inlay tympanoplasty: a study in Indian scenario. Indian J Otolaryngol Head Neck
Surg. 2002;54:11-3.
5. Chalishazar U. Fat plug Myringoplasty. Indian J Otolaryngol Head Neck Surg. 2005;57:43-4.
6. Chaudhary N, Anand N, Taperwal A, et al. Role of autografts in the reconstruction of ossicular chain in intact canal wall proce-
dures. Indian J Otolaryngol Head Neck Surg. 2003;55:157-9.
7. Desai AA, Aiyer RG, Pandya VK, et al. Postoperative sensorineural hearing loss after middle ear surgery. Indian J Otolaryngol
Head Neck Surg. 2004;56:240-2.
8. Desarda KK, Bhisegaonkar DA, Gill S. Tragal perichondrium and cartilage in reconstructive tympanoplasty. Indian J Otolaryngol
Head Neck Surg. 2005;57:9-12.
9. Fischer H, Gubisch W, Sinha V. Auricular reconstruction—Our experience at marine hospital Stuttgart, Germany. Indian J Otolar-
yngol Head Neck Surg. 2010;62:162-7.
10. Gupta N, Mishra RK. Tympanoplasty in children. Indian J Otolaryngol Head Neck Surg. 2002;54:271-3.
11. Krishnan A, Reddy EK, Chandrakiran C, et al. Tympanoplasty with and without cortical mastoidectomy—A comparative study.
Indian J Otolaryngol Head Neck Surg. 2002;54:195-8.
12. Mohindra S, Panda NK. Ear surgery without microscope; it is possible. Indian J Otolaryngol Head Neck Surg. 2010;62:138-41.
13. Nagle SK, Jagade MV, Gandhi SR, et al. Comparative study of outcome of type I tympanoplasty in dry and wet ear. Indian J Oto-
laryngol Head Neck Surg. 2009;61:138-40.
14. Panda NK, Verma R, Kumar JA. Auto-tympanomastoidectomy in a Case of Cholesteatoma with Foreign Body. India J Otolaryngol
Head Neck Surg. 2011;63:S68-70
15. Paul J, Kanotra S, Bhagat S. Fat graft myringoplasty. Indian J Otolaryngol Head Neck Surg. 2005;Special issue-II:421-7.
16. Raj A, Meher R. Endoscopic transcanal myringoplasty—A study. Indian J Otolaryngol Head Neck Surg. 2001;53:47-9.
17. Ravikumar A, Chowdhery A, Senthil K. Hearing benefit in middle ear reconstructive surgery: a comparative study of the current
methods. Indian J Otolaryngol Head Neck Surg. 2005;57:210-4.
18. Roychaudhari BK. 3-flap tympanoplasty—A simple and sure success technique. Indian J Otolaryngol Head Neck Surg. 2004;56:196-200.
19. Sengupta A, Anwar T, Ghosh D, et al. A study of surgical management of chronic suppurative otitis media with cholesteatoma and
its outcome. Indian J Otolaryngol Head Neck Surg. 2010;62:171-6.
20. Sharma DK, Singh S, Sohal BS, et al. Prospective study of myringoplasty using different approaches. Indian J Otolaryngol Head
Neck Surg. 2009;61:297-300.
21. Singh BJ, Sengupta A, Das SK, et al. A Comparative of different graft materials used in myringoplasty. Indian J Otolaryngol Head
Neck Surg. 2009;61:131-4.
22. Singh J, Jain R, Agrawal S, et al. Myringoplasty with Partial Thickness Cartilage with Perichondrium. Indian Journal of Otology.
2005;11:10-2.
23. Singh M, Rai A, Bandyopadhyay S. Middle ear microsurgery in India: A retrospective audit study. Indian J Otolaryngol Head Neck
Surg. 2006;58:133-6.
24. Singh M, Jain S, Rajput R, et al. Retrospective and Prospective Study of Singapore Swing Method on Healing of Mastoid Cavity.
Indian J Otolaryngol Head Neck Surg. 2010;62:365-71.
25. Taneja MK. Endomeatal Mastoidectomy. Indian Journal of Otology. 2008;14:3-5.
26. Vijayendra H, Mahadeviah A, Surendran K, et al. Micro-ear surgery—its purpose and procedure for tubotympanic pathology.
Indian J Otolaryngol Head Neck Surg.2005;57:360-3.
27. Vijayendra H, Rangam CK, Sangeeta R. Comparative study of tympanoplasty in wet perforation V/S totally dry perforation in
tubotympanic disease. Indian J Otolaryngol Head Neck Surg. 2006;58:165-7.
28. What is blunting of the anterior angle of the tympanic membrane with the canal wall? Does it alter the role of tympanic mem-
brane in sound transmission? Reader’s Forum-25. Indian J Otolaryngol Head Neck Surg. 2001;53:328-9.
56 Operations of Nose and
Paranasal Sinuses
It is fear alone that is death. You have to go beyond all fear. So from this day, be fearless.
It is the level-headed man, the calm man, of good judgment and cool nerves, of great sympathy and love,
who does good work and so does good to himself.
—Swami Vivekananda
Points of Focus ¯¯Inferior Meatal Antrostomy
¯¯Caldwell-Luc Operation
Sinus Operations
¯¯Preoperative Assessment Indications, Contraindication
¯¯Diagnostic Nasal Endoscopy Anesthesia, Position
Instruments
Indications Techniques
Instruments Postoperative Care
Techniques Complications
¯¯Endoscopic Sinus Surgery Surgery of Nasal Septum
Indications, Contraindications Indications, Contraindications
Anesthesia Anesthesia
Preparations Techniques
Position of Patient Instruments
Techniques
Postoperative Care ¯¯Submucous Resection of Nasal Septum
Complications ¯¯Septoplasty
¯¯Antral Puncture ¯¯Postoperative Care
Indications, Contraindications ¯¯Complications
Anesthesia and Position ¯¯Clinical Highlights
Instruments
Techniques
Complications
Sinus Operations it’s low in cases with recurrent polyps, severe allergies, past
external procedures and immunocompromised state.
The current trend for treating the sinonasal diseases is func-
tional endoscopic sinus surgery (FESS), which will be dealt Preoperative assessment
in detail but it is important to have knowledge of external A thorough history and physical examination is of paramount
approaches, which used to be the mainstay of treatment in importance and must include following points:
recent past. FESS is considered for patients with refractory 1. History: Chief complaints and associated history of allergy,
rhinosinusitis or its complications. The success rate of FESS is
good in patients with chronic or recurrent rhinosinusitis while asthma, aspirin sensitivity, polyps and facial pain, conges-
tion, hyposmia, nasal obstruction and purulent discharge.
558 Past medical and surgical history.
2. Examination: Complete head, neck and ocular examination
Section 8 w Operative Procedures and Instruments Fig. 1: Sinuscopy examination with CCTV attachment. Right
and review of systems. hand holds the suction cannula
3. Nasal endoscopy examination: Look for septum deviation,
Indications
character of mucosa and polyps. Detailed nasal endoscopy Sinuscopy facilitates in diagnosing the nose, paranasal sinuses
examination is described in other section of this chapter. (PNS) and nasopharynx diseases:
a. First pass: Examine floor, nasolacrimal duct and naso- Locate the site of nose bleed.
Biopsy from nose, PNS and nasopharynx lesions.
pharynx on first pass. Assess the response to treatment of nose, PNS and naso-
b. Second pass: Examine middle meatus, sphenoeth-
pharynx diseases.
moidal recess on second pass at a 30° angle from floor.
Notice anatomical variations especially of osteomeatal Instruments
complex such as paradoxical, lateralized middle turbi- 4 mm 0° and 30° sinuscopes.
nate or concha bullosa, deviated nasal septum or spurs, 2.7 mm 0° and 30° sinuscopes in cases of children and
medialized uncinate process, hypertrophy of ethmoidal
bulla, polyps, purulent discharge and big agger nasi narrow nasal cavity.
cells. Freer’s elevator.
c. Third pass: Examine frontal recess during the final pass. Suction cannula.
4. Preoperative antibiotics and steroids: They help in infection Biopsy forceps.
and inflammation, especially in cases with polyps, chronic Antifog solution/savlon to avoid fogging.
rhinosinusitis and reactive airways.
5. Computerized tomography of nose and paranasal sinuses: CT Techniques
scan limited study coronal cuts in bone window is prerequisite Anesthesia: Mix 4% xylocaine in equal quantity of
for endoscopic sinus surgery (ESS).
a. Method: Detailed sinus CT evaluation includes axial and oxymetazoline hydrochloride. Instill these drops into the
coronal views, with 2–5 mm intervals, printed in both nose and then pack nasal cavity with packing impregnated
soft tissue and bony windows. with this solution.
b. Prerequisite: To evaluate the anatomy and the pattern of Position of patient: Patient is kept in either sitting or supine
rhinosinusitis, CT is obtained 2–4 weeks after medical position (Fig. 1).
treatment. Method: For thorough and complete examination, the
c. Examination: Look for the following findings: scope is passed through the standard three paths. The
–– Normal anatomy: Notice the presence of agger nasi examination is conducted while inserting and withdrawing
the scope.
cells, frontal cells, infraorbital cells, attachment of First pass (0° sinuscope): It examines the nasal vestibule,
uncinate process, course of internal carotid artery
and optic nerve. nasal cavity in general, septum, inferior meatus and
–– Pathology: Retained fluid, thickened mucosa, nasopharynx.
polyps, anatomical abnormalities (septal deviations), –– The scope is passed up to the nasopharynx through
and evidence of expansion, erosion, or dehiscence,
calcifications and hyperintense signals (fungus and the inferior meatus. Slight pressure over the lacrimal
tumors). sac may show the opening of nasolacrimal duct in
–– Anatomic variations: The anatomic variations, which the inferior meatus.
can predispose to complications during ESS, include –– Note the septal deviation or spur, nature of nasal
lamina papyracea medial to maxillary ostium, dehis- discharge, and color of mucous membrane, opening
cence of lamina papyracea, internal carotid artery of the eustachian tube, walls of nasopharynx, and
or optic nerve, hypoplasia of maxillary sinus, low or upper surface of soft palate.
sloping fovea, sphenoethmoidal cells and sphenoid Second pass (0° sinuscope): It examines the posterior part
sinus septa attached to carotid. of middle turbinate, sphenoethmoidal recess, superior
Incidental sinus opacification is seen in 25–30% of sinus scans.
6. Magnetic resonance imaging: Magnetic resonance imaging
(MRI) is indicated in cases of bony dehiscence or erosion,
intracranial invasion, and encephalocele, and in differenti-
ating tumors from fluid within sinuses.
Diagnostic nasal endoscopy (sinusco-
py) (Fig. 1)
The brighter illumination, magnification, and angled view of
endoscopes (sinuscopes) facilitate examination of all the cleft
and crevices of nose and nasopharynx.
meatus, superior turbinate and openings of the sphe- 559
noid sinus (in the posterior wall of sphenoethmoidal
recess between the nasal septum and superior turbi- Fig. 2: X-ray PNS PA view Water’s position showing right maxil- Chapter 56 w Operations of Nose and Paranasal Sinuses
nate) and posterior ethmoid sinuses (in the superior lary sinus haziness
meatus). Source: Dr Jayesh Patel, Consultant Radiologist, Anand, Gujarat
–– The scope is passed medial to the posterior part of
Encephalocele.
middle turbinate and progresses up to the spheno- Pituitary tumors.
ethmoidal recess between the nasal septum and Optic nerve decompression.
superior turbinate. Orbital decompression in Graves’ disease.
Third pass (30° sinuscope): It examines the osteomeatal Choanal atresia.
complex in the middle meatus such as uncinate process,
bulla ethmoidalis, hiatus semilunaris, sinus of turbinate Contraindications
(space lateral to middle turbinate), basal lamina, and The contraindications include following conditions, which are
the frontal recess. better tackled by the external approaches:
–– The sinuscope is passed into the middle meatus Intracranial complications.
usually from the anterior aspect but in some cases Orbital cellulitis with visual field defects.
it is entered from behind where it is wider and the Osteomyelitis.
structures are examined from behind forward. If Aggressive fungal infections such as mucormycosis.
needed middle turbinate can be gently retracted
medially with the help of Freer elevator.
Complication: Bleeding can occur due to improper manipu-
lation of instruments and is usually controlled by the appli-
cation of vasoconstrictor pledgets.
ENDOSCOPIC SINUS SURGERY
The endoscope has revolutionized the diagnosis and treatment
of diseases of nose and paranasal sinuses. Now the first line of
surgical treatment of rhinosinusitis is FESS. FESS has demon-
strated success rates of 76–98%.
The philosophy of FESS is minimal (functional) surgery with
mucosal preservation to achieve physiological drainage and
ventilation of sinuses and healing. FESS is targeted to diseased
sinuses and the normal sinuses are left alone. Aggressive
removal of mucosa is avoided as it leads to postoperative
healing problems.
Indications Anesthesia
Recurrent and chronic rhinosinusitis, which do not respond Local anesthesia with sedation: Endoscopic sinus surgery in
to medical therapy (Fig. 2). adults is usually done under local anesthesia and sedation. It
Nasal polyps both ethmoidal and antrochoanal. improves safety, as manipulations of orbital perisoteum and
Foreign body. dura are painful. The standby anesthesiologist monitors the
Septoplasty. vital parameters such as blood pressure, pulse, respiration,
Dacryocystorhinostomy. temperature and oxygen saturation.
Epistaxis especially uncontrolled posterior bleeding and General anesthesia: It is preferred in pediatric patients,
anxious adults, in anticipated long cases and computer-
ligation of sphenopalatine artery. assisted navigation systems.
Headache and facial pains: Due to nasal septal deviation
Preparations
and concha bullosa. Topical decongestants and anesthetics are administered in
Complications of rhinosinusitis such as orbital abscess. nose before the patient comes to operation theater (OT). Local
Cerebrospinal fluid rhinorrhea: Traumatic and iatrogenic. injection with 1% lignocaine with 1:100,000 epinephrine is
infiltrated to nasal septum and dorsum, inferior and middle
Patch material includes mucosal grafts, fascia grafts and turbinates (infraorbital block) canine fossa, and greater palatine
synthetic products. foramen. A small Foley catheter No. 8 or expandable sponges
Fungal mycetoma: CT shows heterogeneous and micro- in nasopharynx prevents blood pooling in oropharynx.
calcifications.
Juvenile nasopharyngeal angiofibroma. Position of Patient
Tumors of nose and paranasal sinuses such as inverted Patient is placed in supine position. A slight reverse
papillomas. Trendelenburg position with patient rotation towards surgeon
Failed previous surgeries such as external maxillary, helps in reducing blood loss and makes surgeon comfortable.
ethmoidal and frontal procedures.
Mucoceles (frontoethmoid and sphenoid)–marsupializa-
tion.
560 Techniques b. Image-guided navigation: The computer-aided ESS
The endoscopes and microsurgical instruments provide better is of great assistance in revision surgeries and when
Section 8 w Operative Procedures and Instruments precision in the removal of tissue and avoid unnecessary strip- operating near the optic nerve and base of skull and
ping of mucosa. ESS instruments are described in chapter anatomical landmarks are disturbed by the pathology.
Instruments. There are two techniques of ESS: Messerklinger Anatomy can be distorted due to previous surgery,
(anterior to posterior) and Wigand (posterior to anterior). mucocele and extensive polyposis and intracranial and
A. Messerklinger technique: It consists of anterior-to-posterior orbital extensions.
approach. The extent of surgery can be tailored according Postoperative Care
to the extent of disease. It includes following steps: Watch for swelling: Elevation of head and local ice to nose
1. Removal of uncinate process and exposure of infun-
reduce swelling.
dibulum: Uncinectomy and infundibulotomy are done Monitoring of visual and mental status.
with the help of either back-biting forceps or sickle knife Watch for subcutaneous emphysema: Small fracture of
and Blakesley forceps.
2. Identification and widening of maxillary sinus ostium: lamina papyracea can cause subcutaneous emphysema,
Maxillary ostium is situated in the posterior part of infun- which can increase due to positive pressure ventilation,
dibulum and becomes visible after the uncinectomy. It is coughing, vomiting, and blowing of nose.
enlarged anteriorly and posteriorly. Antibiotics: Intraoperative as well as postoperative for 7–10
3. Anterior ethmoidectomy: Removal of ethmoidal bulla days.
(bullectomy) is performed with curette or Blakesley Steroids: Reduces mucosal edema and manage allergy.
forceps. Analgesics relieve the pain.
4. Frontal sinusotomy: Exposure and cleaning of frontal Other agents: Allergy management, antifungal agents, and
sinus ostium is done in the event of frontal sinus disease. leukotriene inhibitors; and irrigations are administrated as
Many surgeons prefer to do this step in last. The posi- per the need of the case.
tion of frontal sinus opening varies depending on the Removal of nasal packing: It is removed at the time of
insertion of uncinate process. It is situated lateral to discharge that is usually 24 hours after the surgery.
anterior attachment of middle turbinate, medial to Topical saline and decongestants: Saline nasal spray and a
lamina papyracea, anterior to anterior ethmoidal artery short course of nasal decongestant after the removal of
and posterior to agger nasi cells. nasal packing.
5. Identification of roof of ethmoid: Remove the remaining Nasal saline irrigations remove blood clots, crusts and
anterior ethmoidal cells and identify the middle turbi-
nate basal lamella. secretions.
6. Posterior ethmoidectomy (removal of posterior ethmoidal Removal of stenting: Plan for the stent removal if that is used.
cells): This thin basal lamella separates the anterior Avoid strenuous activity and nose blowing and medicines
ethmoidal cells from the posterior ethmoid cells. It
is penetrated in the lower and medial part and the that increase risk of bleeding.
diseased posterior ethmoid cells are removed. First postoperative visit: It varies from patient to patient
The presence of posterior ethmoid Onodi cells, which
extends into sphenoid bone lateral and superior to and is usually after 3–6 days. Some patients need frequent
sphenoid sinus, places the optic nerve at risk. cleaning while others may need none. Debridement of old
7. Sphenoid sinusotomy: Opening of the anterior wall of blood and crusts promotes healing and restores mucociliary
the diseased sphenoid sinus is done in last. The inspis- function. Fixed clots and crusts are not removed as they
sated secretions and pus is aspirated. The sinus can be cause damage to mucosa and bleeding. Middle turbinate
entered either by directly enlarging the opening of the should not get lateralized.
sphenoid sinus or through the created anterior and
inferior ethmoid cavity. Complications
8. Packing: Small Merocel packing in middle meatus keeps Complications of ESS are usually divided into two categories—
the middle turbinate medial and prevents adhesions. minor and major (Table 1).
B. Wigand technique: It involves posterior-to-anterior
approach and include following steps: The most common minor complication of FESS is the
1. Partial resection of middle turbinate. adhesions and major complications are bleeding, blindness
2. Opening of posterior ethmoidal cells. and intracranial injury.
3. Removal of anterior wall of sphenoid sinus.
4. Identification of skull base within sphenoid sinus. Subcutaneous emphysema: Small fracture of lamina papy-
5. Removal of anterior ethmoids. racea can cause subcutaneous emphysema, which can
C. Advanced techniques: increase due to positive pressure ventilation, coughing,
a. Powered instruments: Powered instrument such as soft vomiting and blowing of nose.
tissue shaver (microdebrider) helps in not only reducing
bleeding but is also excellent in removing polyps and Bleeding: The common arteries, which can be injured and
soft tissue masses. Bone cutting drills are used during cause major bleeding, are posterior septal artery below
the surgery of frontal sinus and lacrimal sac. sphenoid sinus and arteries from the internal maxillary
artery into middle turbinate. Injury to carotid artery needs
immediate angiography for balloon occlusion.
Orbital hematoma: Rapidly expanding orbital hematoma
occurs due to the injury to anterior or posterior ethmoidal
artery.
Table 1 Minor and major complications of endoscopic sinus surgery 561
Minor Major
Minor bleeding Orbital Intracranial
Hyposmia Orbital hematoma Fracture of skull base
Extraocular muscle injury: Intracranial bleeding
Synechia Diplopia CSF rhinorrhea, stroke
Headache Injury optic nerve: Blindness Meningitis, brain injury
Periorbital ecchymosis Decreased visual acuity Carotid injury, death
Periorbital emphysema Pneumoencephalus
Dental pain Nasolacrimal duct or sac injury
Lamina papyracea injury Others: Anosmia, bleeding
Facial pain
Clinical features: It leads to elevated intraorbital pressure Technique Chapter 56 w Operations of Nose and Paranasal Sinuses
and blindness. The medial wall of maxillary antrum is punctured through the
lateral wall of inferior meatus with Lichwitz trocar and cannula
Treatment: It needs immediate control of bleeding (Fig. 3). A point 1.5–2.0 cm posterior to anterior end of infe-
(cautery or clipping) and reduction of intraorbital pres- rior turbinate and near the attachment of concha is selected
sure (orbital decompression or lateral canthotomy and for puncture because the bone is very thin here and is easily
cantholysis). The treatment also includes immediate pierced. The direction of the trocar and cannula is towards
removal of the nasal pack, administration of steroids the ipsilateral ear. After piercing the nasoantral wall, trocar is
and ophthalmologist consultation. removed. The cannula is advanced gradually till it reaches the
posterior antral wall and then is withdrawn a little. The antrum
Cerebrospinal fluid leak: The overlay and the underlay graft is then irrigated with 37°C and 20 ml normal saline (Fig. 4) or
materials used in cases of cerebrospinal fluid leak (CSF) due Hagginson’s syringe (Fig. 5) till the return is clear. The cannula
to skull base injury include nasal mucosa, fascia (temporalis), is removed and a pack is kept in the inferior meatus if bleeding
fat, muscle, acellular dermal graft, and bone or cartilage. is present.
Fibrin glue adds support and assists healing.
Complications
ANTRAL PUNCTURE OR PROOF PUNCTURE Swelling of cheek: It can occur if cannula goes into soft
In antral puncture (AP), medial wall of maxillary sinus is punc-
tured in the region of inferior meatus for antral irrigation (lavage). tissues over the anterolateral wall of the maxilla. Puncture
of the posterior antral wall will result in the swelling of
Indications posterior part of cheek.
Diagnostic: For collecting the specimen of the antral Orbital injury and cellulitis: They occur when trocar and
cannula perforates the floor of orbit, which is the roof of
contents for cytological (early malignancy) and identifica- maxillary antrum.
tion of microorganisms (staining, culture and sensitivity). Bleeding: It may be brisk in some cases.
Thin amber-colored fluid with cholesterol crystals indi- Air embolism: Though rare it may prove fatal. Avoid air insuf-
flation into the antrum after irrigation.
cates antral cyst.
Blobs of mucopus indicate hyperplastic sinusitis.
In cases of suppuration, foul smelling pus mixes with
irrigating saline.
Therapeutic: For washing out the pus in chronic and
subacute maxillary sinusitis (Fig. 2).
Contraindications
Acute maxillary sinusitis: In this condition AP can lead to
osteomyelitis.
Under-developed maxilla with thick bony wall
Fracture Maxilla
children (<3 years)
Anesthesia and Position
Local anesthesia and sitting position in adults: A pack of 4%
lignocaine with adrenaline in inferior meatus is kept for
10–15 minutes. Middle meatus is decongested, which help
in opening the maxillary ostium and easy return of fluid.
General anesthesia and tonsillectomy position: They are used
in children and anxious uncooperative adults.
Instruments Fig. 3: Antrum puncture. The medial wall of maxillary antrum is
Lichtwitz trocar and cannula (see chapter Instruments) is used punctured through the lateral wall of inferior meatus with Lichwitz
for proof puncture (antral lavage). It perforates the lateral wall
of inferior meatus. This area is easily accessible and safe region. trocar and cannula
562 CALDWELL-LUC OPERATION
Caldwell-Luc operation, which was described by George Caldwell
Section 8 w Operative Procedures and Instruments in 1893 and Henry Luc in 1897, consists of two antrostomies:
canine fossa (through sublabial approach) and inferior meatus
(intranasally). It allows for both dependent drainage and irrigation.
It has a long history in the treatment of paranasal sinus diseases.
This operation has held on its own for 100 years. Until the
last quarter of the 20th century, this operation was the mainstay
of treatment for chronic sinusitis. The postoperative factors
coupled with advances in CT scan and endoscopes, culminated
in the development of FESS. Though some infrequent indica-
tions still remain, FESS has now replaced the Caldwell-Luc
operation as the treatment of choice in sinusitis.
Fig. 4: Proof puncture (antral lavage). Antrum is irrigated with Indications
20 ml syringe The main indication is chronic maxillary sinusitis. Other indica-
tions include:
Complications of acute maxillary sinusitis.
Removal of foreign bodies or root of tooth.
Dental cyst.
Oroantral fistula.
Biopsy in suspected cases of neoplasm.
Recurrent antrochoanal polyp.
Fracture of maxilla or blow out fractures of the orbit.
Horgan’s transantral ethmoidectomy.
Pterygomaxillary space surgery such as ligation of maxillary
artery through pterygopalatine fossa approach and vidian
neurectomy.
In combination with endoscopic approach: Orbital decom-
pression and removal of inverting papillomas.
Contraindication
It is contraindicated in children below 17 years of age.
Fig. 5: Antrum irrigation with Hagginson’s syringe Anesthesia
General anesthesia with cuffed endotracheal intubation is
INFERIOR MEATAL ANTROSTOMY preferred but can even be done under local anesthesia.
In this procedure, an opening is made in the medial wall of
maxillary antrum through the lateral wall of inferior meatus. Position
Indication: Refractory cases of chronic purulent maxillary Patient is placed in supine position and face is turned slightly
to the opposite side. Head end of the table is raised.
sinusitis.
Contraindications: Polypoidal hypertrophy, osteitis and Instruments
See the chapter on Instruments.
suspected malignancy.
Anesthesia and position: It can be done under local or Techniques (Figs 6A and B)
Preparation: Local 1% or 2% lignocaine with epinephrine
general anesthesia. Patient is placed in same position as in
submucous resection (SMR) operation. (1:100000) is infiltrated in gingivobuccal and gingivo labial
Technique: After fracturing the inferior turbinate medially sulcus. Nose is packed with cotton pledgets soaked in
and superiorly with a large periosteal elevator, the lateral topical decongestant.
wall of inferior meatus is perforated with a curved hemostat. Incision: Lip retractor retracts the upper lip. Cheek retractor
This perforation is further enlarged to 1.5–2 cm diameter can also be used for making a horizontal incision with its
close to the floor of nose with Kerrison’s bone forceps, Luc’s ends upward in the gingivolabial sulcus below the canine
or side-biting ring forceps. The sinus content pus/debris is fossa. The incision cuts through mucous membrane and
aspirated by suction. periosteum. In children this incision is made above the
Instruments are described in chapter Instruments. level of secondary dentition, which can be seen in plain
Complications: They are occasional and include bleeding radiograph.
and injury to nasolacrimal duct. Packing into the sinus and Mucoperisoteal flap: Periosteum elevator is used for
nose is done in cases of severe bleeding.
Postoperative Care 563
Local ice packs: They prevent edema, hematoma and
discomfort.
Pack removal: Sinus and nose packing is usually removed
in 24–48 hours.
Antibiotic: Postoperative antibiotic is given for 1 week.
Instruction to patient: Patient is instructed to avoid blowing
of nose for 2 weeks because it can cause surgical emphy-
sema.
Complications Chapter 56 w Operations of Nose and Paranasal Sinuses
Bleeding is controlled with packing.
A Anesthesia of the cheek may last for few weeks or months
and occurs due to stretching or injury to infraorbital
nerve. Gentle sublabial retraction prevents this compli-
cation.
Anesthesia of teeth (devitalized teeth).
Facial asymmetry.
Recurrent sinusitis and polyposis.
Dacryocystitis due to injury to nasolacrimal duct.
Sublabial oroantral fistula.
Osteomyelitis of maxilla.
B SURGERY OF NASAL SEPTUM
Figs 6A and B: Caldwell-Luc operation. (A) Incision; (B) Canine If needed the trimming of enlarged turbinates, nasal valves
fossa antrostomy repair and correction of external nose deformity are done
together with the correction of deviated nasal septum.
elevating the periosteum and soft tissues. The mucoperios-
teal flap is raised superiorly up to the level infraorbital nerve, Indications
which should not be stretched and damaged. Deviated nasal septum (DNS) causing nasal obstruction,
Canine fossa antrostomy: Using 4 mm osteotome and
hammer or a drill, a window is made in the antrum through recurrent headaches, rhinosinusitis and otitis media.
the canine fossa. Killian’s nasal gouge (bayonet-shaped) Recurrent epistaxis from spur and convex side of DNS.
can be used for opening the maxillary antrum. The window Septorhinoplasty for external nasal deformities.
is enlarged as necessary using Kerrison’s punch or Citelli Hypophysectomy: Trans-septal trans-sphenoidal approach.
sphenoid punch. Vidian neurectomy: Trans-septal approach.
Removal of disease: The maxillary sinus pathology and Septal cartilage graft: It is obtained for rhinoplasty and
diseased mucosa (cyst, benign tumor, and foreign body)
can be removed with elevators, curettes and forceps. Luc’s repair of CSF leak.
forceps can be used to remove polyps, growth and bone
pieces. Contraindications
Intranasal antrostomy: A curved hemostat is pushed into Children: A conservative surgery (septoplasty) can be
the antrum below the inferior turbinate at least 1 cm behind
the anterior end of middle turbinate (to avoid damage to considered.
nasolacrimal duct). This opening is widened to about 1.5 cm Acute URI: Acute episode of nasal, sinus or respiratory
in diameter with Kerrison’s and side biting forceps.
Endoscopic examination: The maxillary sinus can be exam- infection.
ined through both the antrostomies with the help of Medical: Bleeding diathesis and uncontrolled diabetes or
endoscopes.
Packing: Ribbon gauze packing which is impregnated with hypertension.
liquid paraffin or Furacin (0.2% w/w nitrofurazone) ointment
is prepared. One end of the packing is brought out from the Anesthesia
nasoantral window into the nose and the rest is packed in Local anesthesia with sedation: It is preferred in adults.
maxillary antrum. Packing is also done in the nose. Dressing
forceps (Tilley’s, Wilde’s or Hartmann’s) can be used for Topical and local xylocaine with epinephrine provides both
packing. The packing takes care of bleeding. analgesia and decongestion. Infiltration of nasal septum
Closure: Sublabial incision is closed with absorbable suture. with 1% xylocaine and 1:100,000 epinephrine in subperi-
chondrial and subperiosteal planes is done with 27-guage
needle. The injection begins at caudal end of septum and
then goes posteriorly and includes both sides of septum
and floor around maxillary crest.
In cardiac patients, oxymetazoline is preferred over
epinephrine. Maximum dose of xylocaine is 4–7 mg/kg.
564 General anesthesia with endotracheal intubation is used
for children and too much anxious adults.
Position: Patient is placed in reclining position and head
end of the table is raised.
Techniques
Septoplasty is replacing submucous resection of nasal septum.
ESS provides better visualization and facilitates mucoperichon-
drial elevation. The CO2 laser can be used in some selective
cases of septal spurs.
Section 8 w Operative Procedures and Instruments Instruments
See the chapter on Instruments.
Submucous Resection of Nasal Septum Fig. 7: Submucosal resection (SMR) of large central septal seg-
Mucoperichondrial and periosteal flap: It is elevated in the ment preserving L-strut (1 cm dorsal and 1 cm caudal septal seg-
ment)
plane beneath the perichondrium and periosteum. Long
bladed nasal speculums (Killian’s or St Clair Thomson’s) keep A
mucoperiosteal flaps away.
Incision of the cartilage: Cartilage is incised posterior to B
the first incision without cutting the opposite side of Figs 8A and B: Septoplasty. (A) Incision (Killian and hemitrans-
mucoperichondrium. An elevator is passed through the fixion); (B) Plane of dissection (Cottle elevator creating subperi-
cartilage incision and mucoperichondrial and periosteal chondrial pocket)
flap is raised from the opposite side of nasal septum.
Freer’s double ended elevator can be used for the eleva-
tion of mucoperichondrium/mucoperiosteum.
Removal of cartilage and bone: The long bladed nasal spec-
ulum (Killian’s or St Clair Thomson’s) is introduced and flaps
are separated from septal skeleton. The cartilage and bone
that lie between the two flaps are removed with the help of
Ballenger swivel knife and Luc’s forceps. Bony spur or ridge
is removed with the help of gouge (4 mm unguarded osteo-
tome) and hammer. Preservation of 1 cm strip of cartilage
along the dorsal and caudal border of the septum (L-strut)
prevents collapse of the dorsum of nose and retraction of
columella (Fig. 7). Killian’s nasal gouge (bayonet-shaped)
can be used for removal of septal spurs or bony crests and
ridges in nasal septum. It may also be used for removing the
maxillary crest of the deviated nasal bony septum. Double
action bone nibbling forceps can also be used for removing
the bony part of the deviated nasal septum.
Closing: After achieving hemostasis, one or two stitches may
be applied in mucoperichondrial incision.
Packing: Ribbon gauze, which is smeared with furacin
ointment or liquid paraffin, is packed in each side of nose.
Dressing forceps (Tilley’s, Wilde’s or Hartmann’s) can be used
for nasal packing. It prevents collection of blood between
the flaps.
Septoplasty (Figs 8 to Figs 10) Fig. 9: Septoplasty. Separation of septum from the perpendicular
Septoplasty is a conservative septal surgery and retains plate of ethmoid and trimming of the inferior cartilaginous portion
maximum possible septal framework. Mucoperichondrial and displaced from the maxillary crest
mucoperiosteal flap is usually raised only on concave side.
Incision: A 2–3 mm curvilinear incision is made above the Mucoperiosteal flap is elevated on both the sides of maxil-
lary crest and creates two inferior tunnels. The superior and
caudal end of septal cartilage on the concave side. A trans- inferior tunnels on concave side are joined after cutting the
fixion or hemitransfixion incision is employed in cases of fibrous tissue with sharp knife.
caudal dislocation.
Flaps and tunnels: Mucoperichondrial flap is raised
only on the concave side and creates a superior tunnel.
Analgesics control pain. 565
Antibiotic for 5–7 days.
AB Nasal packs: They are removed usually after 24 hours.
Subsequently regular regimen of saline water flushing,
gentle suctioning and instillation of antibiotic ointment
is started.
Decongestant nasal drops and steam inhalations for 5 days.
Sutures are removed on 5th or 6th day.
Patient is instructed to avoid strenuous exercise, trauma to
the nose, blowing and frequent picking of nose for about
3 weeks.
CD E Complications Chapter 56 w Operations of Nose and Paranasal Sinuses
In addition to the complications of anesthesia following compli-
Figs 10A to E: Septoplasty techniques. (A and B) Scoring of cations can occur after septal surgery:
the cartilage on concave side removes the interlocked cartilage Hemorrhage: Repacking of nose is required in severe
stresses; (C and D) Excising the dislocated lower end of sep-
tal cartilage and replacing on the anterior nasal spine or in the reactionary bleeding. The other two types of hemorrhage
groove of nasal crest of maxilla; (E) Shaving the convexity of include primary (during surgery) and secondary (5–7 days
septal cartilage after surgery due to infection).
Septal hematoma: It needs immediate evacuation followed
Septal cartilage: It is separated from the vomer and ethmoid by intranasal packing on both sides of septum with equal
plate. pressure.
Septal abscess: The septal abscess usually occurs due to
Maxillary crest: If needed, it is fractured to realign the septal infection of septal hematoma. It needs immediate incision
cartilage. and drainage.
Perforation: It occurs when both sides of septal mucosa are
Bony septum: It is corrected with removal of the deformed perforated at the same level.
parts. Saddle nose deformity and tip ptosis: Depression of dorsum
of nose in supratip area and tip ptosis occurs when too
Deformed septal cartilage: It can be corrected by scoring, much of septal cartilage is removed along the dorsal border.
cross hatching, morcelizing, shaving or wedge excision. Columella retraction: It can occur when caudal strip of nasal
cartilage is removed.
Other options: Failure: Persistence of deviation is usually the result of inad-
Septorhinoplasty: Some cases need separation of septal equate surgery, which needs revision operation.
cartilage from upper lateral cartilages, implantation Flapping of nasal septum: In this condition two mucoperi-
of cartilage either in the columella or dorsum of nose. chondrial flaps move with respiration to the right or left.
Endoscopic sinus surgery: Sinuscope provides better visu- It happens when too much septal framework is removed.
alization and facilitates mucoperichondrial elevation. CSF leak: Never manipulate perpendicular plate of ethmoid
Laser surgery: The CO2 laser can be used in some selective before incising it as it can damage cribriform plate and
cases of septal spurs, where 2–3 mm height mucoperi- cause CSF leak.
chondrium and cartilaginous spur are completely excised. Toxic shock syndrome: This staphylococcal (sometimes
The opposite side mucoperichondrium is left intact. streptococcal) infection is characterized by nausea,
vomiting, purulent nasal secretions, hypotension and rash.
Closure: Trans-septal sutures keep the mucoperichondrial Treatment: It consists of removal of packing (which
flaps together and prevent hematoma. Nose is packed.
may be the cause), proper hydration of patient, main-
Postoperative Care tenance of blood pressure and administration of proper
Patient is kept in semi-sitting position that prevents oozing antibiotics.
Synechia: Injuries of mucosal fold and turbinates at the same
of blood and swelling. level can lead to formation of adhesions. Asymptomatic
A soft diet in the first two days minimizes active mastication synechia do not need any treatment. They need excision
if they cause nasal obstruction. The two raw surfaces are
and prevent bleeding. kept apart for 2 weeks with polyethylene or silastic sheet.
Clinical Highlights
1. External ethmoidectomy: The anterior ethmoidal artery is located at frontoethmoidal suture line. It lies 24 mm posterior
to the anterior lacrimal crest.
2. Maxillary sinusitis: Most common predisposing factor linked to maxillary sinusitis is mucosal swelling in ethmoid
infundibulum.
3. Caldwell Luc operation: The entry into the maxillary sinus is made through the canine fossa (canine fossa antrostomy).
4. SMR: The complete removal of septal cartilage results in supratip depression of cartilaginous nasal dorsum.
566 FURTHER READING
Section 8 w Operative Procedures and Instruments 1. Ali A, Kurien M, Shyamkumar NK, et al. Anterior skull base: High risk areas in endoscopic sinus surgery in chronic rhinosinusitis: A com-
puted tomographic analysis. Indian J Otolaryngol Head Neck Surg. 2005;57:5-8.
2. Anand V, Santosh S, Aishwarya A. Canine fossa approaches in endoscopic sinus surgery-Our experience Indian J Otolaryngol Head Neck
Surg. 2008;60:214-7.
3. Bansal M. Computer- Assisted functional endoscopic sinus surgery (C-A Fess)—A Review. Indian J Otolaryngol Head Neck Surg.
2000;52:311-4.
4. Baser Brajendra, Kothri Shenal, Kinger Arvind. Endoscopic Approach to Fisch stage II to III-b juvenile Nasopharyngeal Angiofibroma.
India J Otolaryngol Head and Neck Surg. 2011;63:1-4.
5. David S, Raju R, Job A, et al. A comparative study of external and endoscopic endonasal dacryocystorhinostomy-A preliminary report.
Indian J Otolaryngol Head Neck Surg. 2000;52:37-9.
6. Deviprasad D, Mahesh SG, Pujari K, et al. Endonasal endoscopic dacryocystorhinostomy: Our experience. Indian J Otolaryngol Head
Neck Surgery. 2009;61:223-6.
7. AP Singh. Functional Endoscopic Sinus Surgery. Lucknow: Aditya Medical Publishers.
8. Duggal P, Chakravorty S, Azad RK, et al. An epidemiological study on patients undergoing dacryocystorhinostomy. Indian J Otolaryngol
Head Neck Surg. 2006;58:349-51.
9. Gulati SP, Chaudhry D, Kalra V, et al. The role of functional endoscopic sinus surgery (FESS) in patients with asthma with chronic sinusitis.
Indian J Otolaryngol Head Neck Surg. 2008;60:152-5.
10. Marfatia H, Mahajan R, Kirtane M. Tips for the novice nasal endoscopist. Indian J Otolaryngol Head Neck Surg. 2001;53:68-9.
11. Maru YK, Gupta V. Anatomic variations of the bone in sinonasal CT. 2001;53:123-8.
12. Maru YK, Gupta Y. Concha bullosa: Frequent appearance on sinonasal C.T. Indian J Otolaryngol Head Neck Surg. 2000;52:40-4.
13. Maru YK, Patidar K. Complications of endoscopic intranasal ethmoidectomy. Indian J Otolaryngol Head Neck Surg. 2005;Special Issue-
II:379-82.
14. Nayak DR, Balakrishnan R, Murty DK, et al. Endoscopic Septoturbinoplasty: Our Update Series: Indian J Otolaryngol Head Neck Surg.
2002;54:20-4.
15. Nayak DR, Balakrishnan R, Murty KD. Functional anatomy of the uncinate process and its role in endoscopic sinus surgery. Indian J Oto-
laryngol Head Neck Surg. 2001;53:27-31.
16. Nayak DR, Satish KR, Shah P, et al. Endoscopic Dacryocystorhinostomy and retrograde nasolacrimal duct dilatation with cannulation: our
experience. Indian J Otolaryngol Head Neck Surg. 2000;52:23-7.
17. Poorey VK, Chaurpagar R, Tiwari M. Encephalocoele as a complication of intranasal surgery. Indian J Otolaryngol Head Neck Surg.
2005;57:54-6.
18. Prasad KC, Varkki Z, Narsimha Raju PL, et al. Modified Lynch-Howarth-its undisputed relevance today. Indian J Otolaryngol Head Neck
Surg. 2005;Special Issue-I:20-3.
19. Sajithkumar VI, Rathore PK, Mandal S. Interesting case of frontal sinus injury. Indian J Otolaryngol Head Neck Surg. 2002;54:307-8.
20. Shah NJ, Navnit M, Deopujari CE, et al. Endoscopic Pituitary Surgery-A Beginner’s Guide. Indian J Otolaryngol Head Neck Surg. 2004;56:71-
8.
21. Singh M, Jain V, Gupta SC, et al. Intranasal endoscopic DCR (END-DCR) in cases of dacryocystitis. Indian J Otolaryngol Head Neck Surg.
2004;56:177-83.
22. Sinha V, Gupta D, Prajapati B, et al. Endoscopic Dacryocystorhinostomy with conventional instruments: results and advantages over
external Dacryocystorhinostomy. Indian J Otolaryngol Head Neck Surg. 2008;60:207-9.
23. Venkatachalam VP, Bhat A. Functional endoscopic sinus surgery-A newer surgical concept in the management of chronic sinusitis. In-
dian J Otolaryngol Head Neck Surg. 2000;52:13-6.
24. Vishwakarma R, Singh N, Ghosh R. A study of 272 cases of endoscopic Dacryocystorhinostomy. Indian J Otolaryngol Head Neck Surg.
2004;56:257-61.
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26. Gubisch W, Sinha V. Extracoporeal septoplasty- how we do it at Marine hospital Stuttgart Germany. Indian J Otolaryngol Head Neck Surg.
2008;60:16-9.
27. Gulati SP, Wadhera Raman, Kumar Arvind, et al. Comparative evalutation of middle turbinectomy. Indian J Otolaryngol Head Neck Surg.
2010;62:400-2.
28. Gupta M, Mtwani G. Comparative study of endoscopic aided septoplasty and traditional septoplasty in posterior nasal septal deviations.
Indian J Otolaryngol Head Neck Surg. 2005;57:309-11.
29. Gupta N. Endoscopic Septoplasty. Indian J Otolaryngol Head Neck Surg. 2005;57:240-3.
30. Gupta Saroj, Goyal Rashmi. Conv entional Dacryocystorhinostomy Versus Endonasal Dacryocystorhinostomy-A Comparative Study. In-
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32. Hathiram Bachi T, Khattar Vicky S, Sonawane Harshal P, et al. Traumatic Optic neuropathy-our experience. Indian J Otolaryngol Head
Neck Surg. 2010;62:229-35.
33. What are the physiological functions of middle turbinate? Can excision of the same produce serious complications or prove to be ben-
eficial in certain situations? Readers Forum 58. India J Otolaryngol Head and Neck Surg. 2011;63:201-3.
34. Your approach to frontal sinus opening and its variations. What anatomical classification do you follow while searching for the same?
Readers Forum 58. India J Otolaryngol Head and Neck Surg. 2011;63:201-3.
35. What is the physiological function of Uncinate Process? How can you preserve the same and yet do a good FESS? Readers Forum 58.
India J Otolaryngol Head and Neck Surg. 2011;63:201-3.
57 Adenotonsillectomy
Each one thinks his method is best. Very good! But remember, it may be good for you. One food which is very indigestible to one is
very digestible to another. Because it is good for you, do not jump to the conclusion that your method is everybody’s method.
—Swami Vivekananda
Points of Focus ¯¯Steps of tonsillectomy
¯¯Postoperative care
¯¯Preoperative Assessment ¯¯Complications
¯¯Indications of tonsillectomy
Immediate
Part of Other Operations Delayed
Rare
¯¯Indications of adenoidectomy
¯¯Contraindications ¯¯Clinical Highlights
¯¯Preoperative measures
¯¯Steps of adenoidectomy
Preoperative Assessment Indications for Tonsillectomy
1. Family history of coagulation disorders. Recurrent infections and upper airway obstruction are the most
2. History of easy bruising. common indications for Tonsillectomy.
3. Coagulation screening: Prothrombin time, partial thrombo-
Absolute
plastin time, bleeding time and platelet count. Chronic or recurrent tonsillitis
4. If warranted, evaluation of coagulation studies.
5. In cases of adenotonsillar hypertrophy associated with Seven episodes in 1 year, or
Five episodes per year for 2 years, or
severe airway obstruction (severe snoring, obstructive sleep Three episodes per year for 3 years, or
apnea, (OSA) cor pulmonale) Two weeks or more of lost school or work in a year.
a. Polysomnography or sleep sonography Peritonsillar abscess: In children after 4–6 weeks; in adults
b. X-ray chest after second attack.
c. ECG Tonsillitis causing febrile convulsions.
d. Cardiology consultation Cardiac valvular disease associated with recurrent strepto-
6. Further testing for any present systemic medical conditions coccal tonsillitis.
such as history of bronchospasm. Hypertrophy of tonsils causing
7. Screening for sickle cell disease. Excessive snoring or sleep disturbances
8. Beta-human chorionic gonadotropin to rule out pregnancy. Obstructive sleep apnea
9. Angiography to rule out medially placed carotid artery in Cor pulmonale
velocardiofacial syndrome.
568 Dysphagia Acute upper respiratory tract infection or acute tonsillitis.
Interfere with speech. Overt or submucous cleft palate: Conservative adenoidec-
Section 8 w Operative Procedures and Instruments Suspicion of malignancy–Asymmetric tonsillar hypertrophy.
tomy. leaving the lower portion of adenoidal pad intact
A unilateral tonsil enlargement in children can be due to prevents velopharyngeal insufficiency.
lymphoma while in adults epidermoid carcinoma may be the Bleeding disorders such as leukemia, purpura, aplastic
cause. An excisional biopsy is indicated in these conditions. anemia, hemophilia.
Epidemic of polio.
Relative Uncontrolled systemic disease such as diabetes, cardiac
Diphtheria carriers, who do not respond to antibiotics. disease, hypertension or asthma.
Streptococcal carriers, who may be the source of infection During the period of menses in females.
to others. Children under 3 years are at more surgical risks.
Chronic tonsillitis with bad taste or halitosis.
Recurrent sore throats or upper respiratory infections. (URI) Surgical Techniques
Recurrent streptococcal tonsillitis in a patient with valvular Guillotine method: It may be done in mobile tonsil without
heart disease. any fibrosis. Fibrosis of the tonsillar bed occurs due to
Tender cervical adenitis. repeated infections. This technique has been abandoned.
Difficulty in eating. Currently, it is not used but gave good results in the expert
Tonsillolithiasis. hands.
Orofacial and dental abnormalities. Dissection and snare method (with sharp instrumentation):
Failure to thrive. More operative bleeding but less postoperative pain.
Enuresis. Electrocautery (Bovie and bipolar): Less operative bleeding
Obstructive tonsils in infectious mononucleosis not but more postoperative pain
Laser: CO2 or KTP laser surgery.
responding to medical therapy. Cryosurgery: Tonsil is frozen with two applications of cryo-
probe for 3–4 minutes each time and then allowed to thaw.
Part of Other Operations Tonsils undergo necrosis and then fall off and leave a granu-
Palatopharyngoplasty for OSA syndrome. lating surface. Bleeding is less because of the thrombosis
Glossopharyngeal neurectomy. CN IX is severed in the bed of vessels.
of tonsil. Newer Technologies
Removal of styloid process. The newer methods are being employed to perform tonsil-
lectomy and include:
Indications for Adenoidectomy Harmonic scalpel: Ultrasonic technology cuts and coagu-
Adenoidectomy may be done alone or in combination with
tonsillectomy. Adenoids are usually removed first and the lates tissues. Tonsillectomies have been done but cannot
nasopharynx is packed. Adenoidectomy prevents recurrence be used for adenoidectomy. Each blade used for operation
of dental abnormalities after orthodontic treatment. increases the cost.
Adenoid hypertrophy causing Coblation: This technology utilizes the radio‑ frequency
bipolar electrical current. It claims effective dissection with
Excessive snoring less postoperative pain from thermal injury. It has been used
Mouth breathing for completion of tonsillectomy, adenoidectomy (for small
OSA syndrome or sleep disturbances adenoid pads and not for large obstructive adenoids), and
Cor pulmonale intracapsular tonsillectomy (tonsillotomy in which tonsil
Failure to thrive is debulked). Tonsillotomy leaves behind small amount of
Enuresis tonsil tissue covering the constrictor muscle.
Dysphagia Powered instrumentation: Microdebrider shaver allows
Speech abnormalities such as rhinolalia clausa precise, rapid and safe removal of tissue. It can be used
Craniofacial growth abnormalities. for adenoidectomy and tonsillotomy (intracapsular tonsil-
Purulent adenoiditis lectomy).
Recurrent rhinosinusitis
Middle ear infections Preoperative Measures
Chronic secretory otitis media No solid food by mouth for 8 hours; clear liquids may be
Chronic recurrent acute otitis media
Benign CSOM with recurrent ear discharge. allowed for 3 hours before surgery.
Dental malocclusion Sedation with midazolam hydrochloride (0.5–1 mg/kg) 30
The common indications of adenoidectomy include nasal minutes before surgery.
obstruction due to adenoidal hyperplasia, recurrent otitis media Intravenous antibiotic such as ampicillin 20 mg/kg up to 1 g.
and otitis media with effusion in children. Intraoperative dexamethasone (0.5 mg/kg) especially in
Contraindications OSA and children younger than 3 years.
Anemia: Hemoglobin less than 10 g%.
Anesthesia 569
The operation is usually done under general anesthesia with
endotracheal intubation. In cooperative adults, it may be done
under local anesthesia.
Position
Rose’s position (Fig. 1): Supine position with extended head
(Place a pillow under the shoulders). A rubber ring under the
head stabilizes head and prevents its hyperextension.
Surgical Instruments
See the chapter Instruments.
Operative steps Fig. 1: Rose position. The patient lies supine. The head is ex- Chapter 57 w Adenotonsillectomy
When both the tonsils and adenoids are removed in one sitting, tended by putting a sandbag beneath the shoulders
adenoids are removed first. Depending upon the indication,
either tonsils or adenoids may be removed alone.
Adenoidectomy Fig. 2: Boyle-Davis gag in position
Opening of mouth: Boyle-Davis mouth gag is used for Hemostasis: Achieve the hemostasis with packing. Persistent
opening the mouth and retracting the tongue anteriorly bleeders may be electrocoagulated under direct vision.
and inferiorly (Fig. 2). Instruments are discussed in chapter Very occasionally, postnasal pack is required for refractory
Instrument. The built in tongue depressor along with the cases of bleeding.
closed mouth gag is inserted in the mouth after depressing
the lower jaw. The mouth gag is opened gradually. It is Adenoidectomy: It should be modified or avoided in cases of
suspended from Draffin’s bipods and extends the neck submucous cleft palate.
and head. The two pods are assembled together as per the
height at which the tongue blade of the Boyle-Davis mouth Tonsillectomy (Dissection and Snare Method)
gag is suspended. The lower ends of the pods are placed Opening of mouth: Boyle-Davis mouth gag is introduced and
in one of the several depressions of the Magauran’s plate.
Laryngopharyngeal packing: Put a throat pack, which held in position with Draffin’s bipods. See Adenoidectomy
prevents blood and secretions entering esophagus and section.
aspiration of laryngeal clot and leakage of air, oxygen and Laryngopharyngeal packing: Put a throat pack, which
anesthetic agent. prevents blood and secretions entering esophagus and
Examination: Nasopharynx and adenoids are examined after aspiration of laryngeal clot and leakage of air, oxygen and
retracting the soft palate with curved end of the tongue anesthetic agent.
depressor. Tonsil dissector and anterior pillar retractor can Tonsil holding: Tonsil is grasped and pulled medially with
also be used in retracting the soft palate and uvula. tonsil holding forceps (Allis clamp, tenaculum, or Denis
Digital palpation: It helps in the following:
–– Assesses adenoids size
–– Pushes the lateral adenoid masses towards the
midline
–– Assesses evidence of submucous cleft palate and
abnormal vessels.
Adenoid curette: St. Clair Thomson’s curette with guard
shaves off the adenoid mass and holds it and prevents
from slipping. Introduce a proper size of adenoid curette
with guard into nasopharynx and feel the posterior border
of nasal septum. Press the adenoid curette backward and
engage the adenoids. The LaForce adenotome may also be
used instead of adenoid curette. Shave the adenoids with
gentle sweeping movement of adenoid curette.
Caution: Flexion of head at this stage will avoid injury
to the odontoid process.
–– Remove the lateral adenoid masses with smaller
curettes.
–– Remove the remaining small tags of adenoids with
punch forceps, smaller plain adenoid curette, Luc
forceps or conchotome.
570 Browne) (Figs 3A and B). Luc forceps may also be used for Packing: A gauze sponge placed in tonsillar fossa for few
this purpose. minutes obtains pressure hemostasis.
Section 8 w Operative Procedures and Instruments Incision: The mucous membrane where it reflects from the
tonsil to anterior pillar is incised either with sharp instru- Other side: Procedure is repeated on the other side.
ment or electrocautery. Tonsil dissection forceps with Removal of packs: Remove the packs from tonsillar fossa
teeth (Waugh’s) can also be used for putting incision in the
mucous membrane and dissection of tonsil. The incision and nasopharynx.
is extended along the upper pole between the tonsil and Hemostasis: Bleeding is usually controlled using electro-
posterior pillar. Electrocautery must not touch metal instru-
ments such as mouth gag and Yankauer suction. Yankauer’s cautery on a low wattage. Large bleeders may be clamped
suction tube is used for suction. and ligated with the help of tonsillar artery forceps. Straight
Dissection: With the help of a blunt curved scissor or tonsil and curved tonsil artery forceps (such as Negus artery
dissector (Thompson dissector or a Fischer knife) separate forceps) are used to catch the bleeding point and ligating
the tonsil capsule from the bed of tonsil. Begin the dissec- the bleeder. Negus Knot tyer helps in tying the ligature knot
tion from the upper pole. Tonsil dissector and anterior pillar up to the tip of curved artery forceps that holds the vessel.
retractor dissect the tonsil and retract the anterior pillar to Tonsil needle is used for sewing the tonsillar pillars together
inspect the fossa for any bleeding. Retraction of the upper for controlling the bleeding, when it is not controlled by
pole medially and towards tongue facilitates the dissection. ligation and cauterization of bleeding points. In these cases
It is continued until lower pole is reached. Tonsil scissors can if gauze is kept in the tonsillar fossa that must be removed
also be used for sharp dissection of the tonsils and cutting within 48 hours.
the ligatures. Caution: Suture ligatures with needle may inadvertently
Caution: Preserve the mucosa and muscle of the poste-
ligate external maxillary and lingual arteries or damage
rior pillar to prevent postoperative nasopharyngeal internal carotid artery.
stenosis. Irrigation and cleaning: Irrigate nasopharynx, oral and nasal
Snare: Eve’s tonsillar snare is threaded over the lower pole cavity thoroughly and evacuate secretions and blood clots
tonsil pedicle, which is amputated with snare and tonsil from laryngopharynx. Stomach may also be suctioned.
removed. When firmly closed, the snare crushes and cuts
the pedicle and minimizes the bleeding. Postoperative Care
A Immediate general care: This includes:
Position: Patient is kept in tonsillar position till full
recovery from anesthesia
Monitor vital signs such as pulse, respiration and blood
pressure
Watch for bleeding from the nose and mouth, vomiting,
swelling (surgical emphysema), pain, and respiratory
distress
OSA and cor pulmonale: In these cases pulse oximetry
and planned mechanical ventilation is important for
persistent hypercapnia until Pco2 levels return to normal.
Diet: Plenty of cold fluids such as cold milk or ice cream.
Sucking of ice cubes helps in relieving pain. The child may
take soft diet on the second day such as custard, jelly, boiled
eggs, porridge or slice of bread soaked in milk. Solid foods
subsequently are allowed as tolerated.
Oral hygiene: Saline gargles 3–4 times a day. Mouth should
be washed with plain water after every feed.
Analgesics: Paracetamol with or without codeine.
Antibiotics: For a week.
Instruction: Report immediately if there is any bright red
colored bleeding from nose or mouth.
B Inpatient Versus Outpatient Procedures
Most patients can be discharged after an observation period
Figs 3A and B: Tonsillectomy. (A) A blunt curved scissor is dis- of 4–6 hours. Patients are instructed to report immediately if
secting tonsil from the peritonsillar tissue while tonsil is grasped there is any bright red bleeding from nose or mouth. Following
with tonsil holding forceps and pulled medially; (B) Wire loop of patients need overnight observation:
tonsillar snare threaded over the tonsil onto its pedicle and cut History of OSA
Younger than 3 years
Presence of other medical problems
History of abnormal bleeding disorder or abnormal coagu-
lation profile
Craniofacial abnormalities such as Down’s syndrome
Tonsillectomy for peritonsillar abscess.
Complications Management: If bleeding is not controlled after 571
The complications are mainly related to pain, bleeding, respira- removal of clot and topical application of dilute
tory obstruction, and pulmonary edema and may even result adrenaline, hydrogen peroxide and with pressure, Chapter 57 w Adenotonsillectomy
in death. Complications are divided here into three groups: then patient is taken to operation room. Under general
immediate, delayed and rare. anesthesia, bleeding vessel is electrocoagulated or
ligated. Approximation of pillars with mattress sutures
Immediate or external carotid ligation may be required in rare
Primary hemorrhage: Bleeding during the operation is cases. Transfusion of blood or plasma may be needed.
Systemic antibiotics control the infection.
usually controlled by pressure, ligation or electrocoagula-
tion. Certain analgesic such as ketorolac should be avoided. Infection: Infection may cause parapharyngeal abscess or
Application of tannic acid, bismuth subgallate or hemostatic otitis media.
agents may be helpful. Coagulopathy must be ruled out.
Residual remnants of adenoid tissue should be completely Pulmonary complications: Aspiration of blood, mucus or
removed. tissue fragments may lead to atelectasis or lung abscess.
Reactionary hemorrhage: Bleeding after the recovery from
anesthesia on the day of surgery is usually controlled by Scarring: Soft palate and pillars.
removing the clot, applying pressure or vasoconstrictor. Clot Tonsillar remnants: The remaining tonsil tags or tissue may
may prevent the clipping action of the superior constrictor
muscle on the vessels. Immediate postoperative bleeding cause repeated infection.
from nose and mouth or vomiting of dark colored blood and Hypertrophy of lingual tonsil: It is compensatory to loss of
rising pulse rate indicate bleeding from the operative site.
Topical decongestant nasal drops may help in controlling palatine tonsils.
nasopharyngeal bleeding. In cases of refractory bleeding, Velopharyngeal insufficiency: Hypernasality is a complication
patient is taken back to operation room and ligation or
electrocoagulation of the bleeding vessels is done under of adenoidectomy. It is usually managed by speech patholo-
general anesthesia. Postnasal pack may be needed in chil- gist. But refractory cases may need reconstructive surgery
dren with adenoidectomy. (pharyngeal flap, sphincteroplasty or posterior pharyngeal
Injury: Oral cavity and oropharyngeal structures such wall augmentation).
as tonsillar pillars, uvula, soft palate, tongue, superior Nasopharyngeal stenosis: It occurs due to scarring after
constrictor muscle, or teeth can be injured during tonsil- excessive damage to nasopharyngeal mucosa (roof, poste-
lectomy. Eustachian tube, pharyngeal musculature and rior and lateral walls) and resection of posterior tonsillar
vertebrae injuries during adenoidectomy can be prevented pillar. These children are difficult to manage.
by avoiding hyperextension of neck and undue pressure Recurrence: Remaining adenoids and tonsil tissue may grow
of curette. again. If plica triangularis near the lower pole of tonsil is
Aspiration and foreign bodies: Such as blood, tissue of tonsil not removed along with tonsil, it may get hypertrophied.
or adenoids or tooth. Atlantoaxial subluxation (Grisel’s syndrome): It leads to stiff
Pulmonary edema: It can occur in cases of OSA and cor neck and spasm of sternocleidomastoid and deep cervical
pulmonale. muscles. Treatment includes intravenous antibiotics and
Edema of tongue, nasopharynx and palate: Need replace- cervical traction.
ment of nasal trumpet and intravenous steroids.
Edema: Face or eyelids. Rare Complications
Surgical emphysema: Due to superior constrictor muscle Pulmonary abscess and mediastinal emphysema.
injury. Horner’s syndrome, optic neuritis, paralysis of glossopha-
Delayed ryngeal and recurrent laryngeal nerve.
Secondary hemorrhage: Bleeding seen between 5th–10th Meningitis and brain abscess.
Submandibular salivary fistula in tonsillar fossa.
postoperative days is the result of sepsis and premature Chronic postoperative pain and Eagle’s syndrome (calcifica-
separation of the membrane.
Clinical features: The common presentation is blood- tion of stylohyoid ligament).
Fires and endotracheal tube explosions.
stained sputum but bleeding may be profuse. Retropharyngeal abscess after adenoidectomy.
Sloughing and severe hemorrhage after accidental suture
ligature of lingual and maxillary arteries and pseudoaneu-
rysm and excessive bleeding due to internal carotid artery.
Injury to aberrant vessels such as carotid artery arising in
fossa of Rosenmuller.
Clinical Highlights
1. Contraindication of tonsillectomy: Children with acute upper respiratory infections [URI (cough, cold, and fever)] should
wait for 3 weeks and get treatment for URI.
2. Post-tonsillectomy earache: This referred otalgia occurs through the glossopharyngeal nerve.
3. Indications of adenoidectomy: The common indications of adenoidectomy include nasal obstruction due to adenoidal
hyperplasia, recurrent otitis media and otitis media with effusion in children.
4. Atlantoaxial dislocation: This complication can occur in children due to adenotonsillectomy, nasopharyngeal infection,
and esophagoscopy.
572 FURTHER READING
Section 8 w Operative Procedures and Instruments 1. Agrawal SR, Jain AK, Marathe D, et al. The effect of bismuth subgallate as haemostatic agent in tonsillectomy. Indian J Otolaryngol Head
Neck Surg. 2005;57:287-9.
2. Bhadoria P, Rathore PK, Mandal S, et al. Role of bupivacaine in reducing post tonsillectomy pain. Indian J Otolaryngol Head Neck Surg.
2006;58:335-6.
3. Dutta NN, Bordoloi BM. Tonsillectomy using harmonic scalpel. Indian J Otolaryngol Head Neck Surg. 2002;54:74-6.
4. George Ajay, Kumar Ranjan, Kumar Sanjay, et al. A randomized control trial to verify the efficacy of Pre-operative intravenous tranexamic
acid in the control of tonsillectomy bleeding. India J Otolaryngol Head and Neck Surg. 2011;63:20-6.
5. Gupta AK, Gupta S, Meena DS, et al. Post-Tonsillectomy pain: Different modes of pain relief. Indian J Otolaryngol Head Neck Surg.
2002;54:136-9.
6. Kurien M, Lepcha A, Mathew J, et al. X-rays in the evaluation of adenoid hypertrophy: its role in the endoscopic ERA. Indian J Otolaryngol
Head Neck Surg. 2005;57:45-7.
7. Mohammad L, Ahmad R, Latoo M, et al. Post-tonsillectomy morbidity—Do steroids help. Indian J Otolaryngol Head Neck Surg.
2006;58:141-3.
8. Ranjan D, Nayak, Pillai S, et al. Traditional versus transnasal endoscopic adenoidectomy—A comparative study. Indian J Otolaryngol
Head Neck Surg. 2005;Special issue-II:383-7.
9. Sharma Karan, Kumar Devinder. Ligation versus bipolar diathermy for hemostasis in tonsillectomy: a comparative study. India J
Otolaryngol Head and Neck Surg. 2011;63:15-9.
10. Somani SS, Naik CS, Bangad SV. Endoscopic adenoidectomy with microdebrider. Indian J Otolaryngol Head Neck Surg. 2010;62:427-31.
11. Taneja MK. Blunt dissection to bipolar forceps tonsillectomy—a comparison. Indian J Otolaryngol Head Neck Surg. 2004;56:67-70.
12. Verma A, Nabhani SA, Khabori MA. Adult tonsillecotomy and day care surgery. Indian J Otolaryngol Head Neck Surg. 2007;59:341-5.
13. What are your indications of TAR in a child? How early you would do it? Do you remove only Adenoids? Do you use Laser or diathermy?
Any advantage? Any specific pre and postoperative management you prefer? Reader’s Forum-36. Indian J Otolaryngol Head Neck Surg.
2005;57:86-8.
58 Endoscopies
You fail only when you do not strive sufficiently to manifest infinite power. As soon as a man loses faith, death comes. He who is
overcautious about himself falls into dangers at every step; he who is afraid of losing honor respect, gets only disgrace; he who is always
afraid of loss always loses.
—Swami Vivekananda
points of Focus ¯ FLexibLe Fiberoptic bronchoScopy (Fob)
Types of FOB
Direct LaryngoScopy (DLS)/ Advantages
MicroLaryngoScopy (MLS)
¯ inDicationS, contrainDicationS eSophagoScopy
¯ aneStheSia, poSition ¯ inDicationS, contrainDicationS
¯ proceDureS ¯ rigiD eSophagoScopy
¯ poStoperatiVe care
¯ coMpLicationS Advantages, Disadvantages
¯ FLexibLe naSopharyngoLaryngoScopy Anesthesia, Position
bronchoScopy Techniques
¯ inDicationS: DiagnoStic, therapeutic Postoperative Care
¯ rigiD bronchoScopy Complications
¯ FLexibLe eSophagoScopy
Advantages Advantages, Disadvantages
Anesthesia, Oxygenation and Ventilation, Position Common Indications
Techniques, Precautions Endoscope and Instruments
Postoperative Care Techniques
Complications ¯ cLinicaL highLightS
Direct LaryngoScopy/MicroLa- selected as per the age of the patient. The larynx, hypopharynx
ryngoScopy and oropharynx are visualized directly with the help of laryn-
goscope.
Laryngoscope used for direct laryngoscopy (DLS) may have Laryngoscope of Microlaryngoscopy (MLS) is self-retaining
either single or twin light carrier which is connected to a cold
light source through a flexible cable. There are several models of laryngoscope. It can be fixed on the chest by a chest piece
laryngoscopes, which are described in chapter of instruments. so that hands of the surgeon remain free for the surgery.
The shape and size of viewing and distal ends and body vary MLS is performed under the magnification of an operating
with the types of laryngoscopes. The size of laryngoscope is microscope (Fig. 1). Microlaryngeal surgery needs special
laryngoscopes, forceps, scissors, dissectors and knives
574 (Figs 2A to G). Other types of laryngoscopy have been Malignant lesions: Early carcinoma of larynx and laryn-
described in chapter Laryngeal Symptoms and Examination gopharynx
Section 8 w operative procedures and instruments of section Larynx, Trachea and Bronchus.
inDicationS Foreign bodies: Larynx and laryngopharynx
Direct laryngoscopy/microlaryngoscopy can be performed for Strictures: Dilatation of laryngeal strictures.
both diagnostic as well as therapeutic purposes.
Diagnostic contrainDicationS
Infants and young children Lesions of cervical spines
Anatomy: Strong gag reflex or overhanging epiglottis Stridor (usually need prior tracheostomy)
Symptoms: Hoarseness, dyspnea, stridor and dysphagia Recent coronary occlusion
Examination of hidden areas: Following areas cannot be Cardiac decompensation.
adequately seen during mirror laryngoscopy: aneStheSia
Oropharynx: Base of tongue, valleculae Usually done under general anesthesia
Infants and young children do not need any anesthesia for
– Hypopharynx: Lower part of pyriform fossa
– Larynx: Infrahyoid epiglottis, anterior commissure, diagnostic DLS.
ventricles and subglottic region. poSition
Biopsy: Tumors of base of tongue, vallecula, laryngo- Patient lies in supine position. Head is elevated 10–15 cm by
placing a pillow under the occipital region or by raising head
pharynx and larynx. flap of operation table. Neck is flexed on thorax and head is
Therapeutic extended on atlanto-occipital joint (barking dog position).
Benign swellings: Removal of papilloma, fibroma, vocal proceDureS
nodule, polyp or cyst Protection of teeth and lips: Examine the patient for neck
Fig. 1: Microlaryngoscopy procedure stability, loose teeth and dentures. Eyes are protected with
a shield and the patient is draped. A gauze piece protects
a the upper teeth against trauma.
c Lubrication: Lubricate laryngoscope with liquid paraffin or
xylocaine jelly.
b Holding of scope: Left hand holds the handle of laryngo-
De scope. Right hand retracts the lips and guides the introduc-
tion of laryngoscope and handle suction and forceps.
Introduction of scope: Laryngoscope is introduced usually
right side of the tongue and is then moved to the midline.
It brings the epiglottis in view.
Lifting of epiglottis: The lifting of epiglottis forward (without
levering laryngoscope on the upper teeth or jaw) provides
view of the interior larynx.
Interior of larynx: The tip of anterior commissure laryngo-
scope is advanced further between the vestibular folds (to
examine the ventricles and anterior commissure) and the
vocal cords (to examine the subglottic region).
Structures examined: The structures, which are examined
serially, include tongue base, valleculae, epiglottis, pyriform
sinuses, aryepiglottic folds, arytenoids, postcricoid region,
false cords, anterior and posterior commissure, ventricles,
vocal cords, subglottic region and mobility of vocal cords
and arytenoids.
Telescope: Angled telescopes facilitate examination of the
undersurface of vocal cords and subglottic region.
F Practical tips for DLS/MLS
g • Protects the lips and teeth. Lips are easily pinched between
Figs 2a to g: Microlaryngoscopy instruments. (A) Laryngoscope the laryngoscope and teeth or gingiva. Upper teeth are easily
holder and chest support; (B) Anterior commissure operating la-
ryngoscope; (C) Laryngeal forceps, upward-angled large size broken by levering the laryngoscope on them.
cupped jaws; (D) Laryngeal forceps, side-angled medium size • Position the head. Extend the neck. Head rests on the
cupped jaws; (E) Suction tube; (F) Laryngeal forceps, upward-
angled fine cupped jaws; and (G) Laryngeal forceps, up-cutting occiput (sniffing position). This position provides the best
angled scissor access to anterior areas.
• Exclude contraindications for extending the neck: Fusion,
instability, Down syndrome.
Do not biopsy both sides of the vocal folds (such as nodules)
close to the anterior commissure to prevent formation of web
poStoperatiVe care inDicationS For bronchoScopy 575
Position: Patient is kept in coma position, which prevents Diagnostic
chapter 58 w endoscopies
aspiration of blood and secretions. Symptoms
Observation: Watch for any spitting of blood, and respiratory – Dyspnea, which may be associated with wheezing
or stridor
distress and cyanosis. They can be due to laryngeal spasm, – Hemoptysis
laryngeal edema, or aspiration of blood. – Unexplained chronic cough
Patient’s follow up instructions: See Box 1. – Hoarseness of voice
– Fever or chest pain suggestive of pulmonary infec-
coMpLicationS tions
Injury to lips, tongue and teeth
Bleeding X-ray chest findings
Laryngeal spasm and edema. – Atelectasis: Segment, lobe or lung
– Opacity: Segment or lobe
FLexibLe naSopharyngoLaryngoScopy – Obstructive emphysema
See chapter Laryngeal Symptoms and Examination in the – Hilar or mediastinal shadows
section Larynx, Trachea and Bronchus. – Pleural effusions.
• Flexible laryngoscopy: If you have difficulty in seeing into Vocal cord paralysis
nasopharynx and oropharynx request the patient to breath Collection of bronchial secretions: Culture and sensitivity,
through nose that will clear the soft tissue obstruction.
acid-fast bacilli, fungus, or malignant cells.
• Valsalva maneuver: By requesting the patient to perform Therapeutic
this maneuver we can better visualize the pyriform sinuses
because that will stent open them. Foreign body removal.
Suction clearance of secretions, blood clots or inspis-
bronchoScopy
sated mucus plugs: Head injuries, chest trauma, thoracic
Bronchoscopy is of two types: rigid bronchoscopy and flexible or abdominal surgery, or coma.
fiberoptic bronchoscopy. Assessment or placement of endotracheal tubes or
double lumen tubes.
box 1: Postoperative instructions to professional voice users Guided percutaneous tracheostomy.
after microlaryngeal surgery Thermal ablation and removal of tumors.
Debridement of benign stenosis.
• First 1–2 weeks: Complete voice rest Balloon dilation.
• Next 1–2 weeks: Graduated voice use. Beginning from 5 Placement of airway stent.
minutes on 1st day, phonation time is doubled each day until rigiD bronchoScopy
the full conversational speech The instruments for rigid bronchoscopy are shown in Figs 3A to
• Next 2–3 months: Relearn how to sing from the basic level H. For the details of these instruments, see chapter Instruments.
and avoid maladaptive behaviors Size of bronchoscope will vary with the age of the patient.
• After 3 months: Return to professional activity after the advantages
permission from your doctor Large instruments can be passed through the larger lumen
• Observe general laryngeal hygiene and have proper of rigid bronchoscope. It is advantageous in the following
hydration conditions:
• Take guaifenesin and perioperative antireflux medications Removal of foreign bodies.
• Take professional help from speech language pathologists
and vocal pedagogue a
• Practice easy onset phonation b
• Avoid vocal abusive behavior
• Use appropriate pitch and vocal intensity. Dc
Laryngeal Hygiene eF
• Drink increased amounts of water (at least eight glasses, i.e. g
64 ounces per day) so that urine becomes lightly colored.
Professional voice users should further increase the amount h
of water if they are traveling by air, are ill, or have demanding
or excessive performance schedule Figs 3a to h: Bronchoscopy (rigid) instruments. (A) Peanut for-
• Avoid use of caffeine because of its diuretic nature eign body grasping forceps, both jaws movable; (B, D and E) Dif-
• Avoid dairy products as they increase the viscosity of ferent size bronchoscopes Jackson pattern; (C and F) Different
secretions and hinder the healthy smooth vibratory function size suction tubes; (G) Cup-shaped oval straight biopsy forceps;
of vocal cords and (H) Peanut foreign body grasping forceps
• Avoid tobacco as it contributes to poor laryngeal hygiene
• Guaifenesin may thin the secretions.
576 Suctioning in profuse hemoptysis. Precautions for Rigid Bronchoscopy
Placements of noncompressible silastic airway stent. • Select proper size of bronchoscope as per the patient’s age.
Section 8 w operative procedures and instruments Coring out tumors. • No force is applied against closed glottis.
Tamponading to a bleeding source. • Avoid repeated removal and introduction of bronchoscope
anesthesia as far as possible. Prolonged procedure (> 20 minutes) may
Usually done under general anesthesia but can be done with cause postoperative subglottic edema in infants and children.
topical surface anesthesia and conscious sedation. • Maintain intravenous line and administer injections of
antibiotic and steroid especially in infants and children.
oxygenation and Ventilation
Intermittent apneic to spontaneous/assisted. postoperative care
Tidal volume through closed system or open system of side Position: Patient is kept in coma position, which prevents
port Venturi jet ventilation. aspiration of blood or secretions.
Patient is kept in humid atmosphere.
position Observation: Watch for any spitting of blood, respiratory
Patient lies in supine position. Neck is flexed on thorax and head distress (inspiratory stridor, suprasternal retraction) and
is extended on atlanto-occipital joint. cyanosis. They can be due to laryngeal spasm, laryngeal
edema, or aspiration of blood. These patients may need
tracheostomy.
techniques complications
Lubrication of scope: Lubricate proper size bronchoscope Injury to teeth and lips.
Transient fever especially after bronchoalveolar lavage.
with liquid paraffin or xylocaine jelly. Bleeding and hemoptysis in cases of inflamed or malignant
Protection of teeth and lips: Examine the patient for neck
tissue.
stability, loose teeth and dentures. Eyes are protected with Hypoxia and cardiac arrest.
a shield and the patient is draped. A gauze piece or teeth Laryngeal spasm or edema.
guard protects the upper teeth against injury. Left hand
thumb retracts the upper lip and teeth while index finger FLexibLe Fiberoptic bronchoScopy
lifts lower teeth. Flexible fiberoptic bronchoscope (FOB) is replacing rigid bron-
Holding of scope: The shaft of bronchoscope is held in right choscope but its utility is limited in children because of the
hand like a pen. Left hand thumb retracts the upper lip and problems of ventilation.
teeth while index finger lifts lower teeth and guides the intro-
duction of bronchoscope with bevel up. types of Fiberoptic bronchoscope
Introduction of scope: Bronchoscope is directed perpendicu- 1. Conventional: Image is viewed at proximal end by the
larly until the uvula is passed. It is introduced usually on the
right side of the tongue and is then moved to the midline. eyepiece or connected to a video display.
It brings the epiglottis in view. 2. Videoscopes: High-resolution true-color rendition of the
Larynx: Tip of epiglottis is identified while lifting the base
of the tongue. Glottis is exposed when epiglottis is lifted image captured by the true color-chip charged couple
forward. Bronchoscope is introduced either directly or device cameras embedded in distal tip of scopes. The
after exposing the glottis with the help of a spatular type recording is possible with digital still images or video
laryngoscope especially in infants, young children and short segments.
neck or thick tongue patients. 3. Outer diameter: It varies from 2.2 (fiber view only and no
Rotate the bronchoscope 90° clockwise to bring its operating channel)–6.4 mm. An average FOB has an outer
diameter of 5.0–5.5 mm. Ultra thin FOB can traverse 12–16
beveled tip in the axis of glottis and enter into the generations of airways.
trachea. Rotate back the scope into its original posi- 4. Length: It varies from 40–60 cm.
tion. 5. Diameter of operating channel: It varies from 1.2–3.2 mm.
Tracheobronchial tree: Gradually advance the scope and An average FOB has 2.0–2.2 mm operating channel, which
examine the entire tracheobronchial tree. Head and neck admits cytology brushes, biopsy forceps and aspiration
are flexed to the left while examining the right bronchial needles. Larger diameter channels are used for larger laser
tree and to the right for left side bronchial tree. In this fibers, electrocautery, cryotherapy probes and expandable
way, axis of bronchoscope corresponds with trachea and balloons.
bronchi. Examine openings of all the segmental bronchi.
Telescope: Straight and angled telescopes provide magnifi- advantages
cation and facilitate detailed examination. Magnification and better illumination
Biopsy: Take biopsy of the lesion of suspicious area. Better documentation (Figs 4 to 6)
Collection of secretions: Collect secretions for exfoliative Smaller size allows examination of subsegmental bronchi
cytology, or bacteriologic examination.
Easy to do even under topical anesthesia 577
It can be performed in cases of neck or jaw abnormalities
or critical illness (bedside examination)
The suction/biopsy channel helps in removing secretions,
inspissated mucous plugs or small foreign bodies
Flexible bronchoscope can be passed through endotracheal
tube.
Bronchoscopy biopsy of the right upper lobe carina/spur: It is
the most dangerous site for biopsy because of the underlying
right pulmonary artery.
eSophagoScopy
Esophagoscopy is of two types: Rigid esophagoscopy and flex-
ible fiberoptic esophagoscopy.
Fig. 4: Mucoid impaction with surrounding edema inDicationS chapter 58 w endoscopies
Source: Dr Rajiv Paliwal, Professor, Chest Medicine, Pramukh
Swami Medical College, Karamsad, Anand, Gujarat Diagnostic
Symptoms: Dysphagia, odynophagia, aphagia, sensation
Fig. 5: Endobronchial mass lesion of a lump or “sticking” in throat, retrosternal burning,
Source: Dr Rajiv Paliwal, Professor, Chest Medicine, Pramukh hematemesis and persistent regurgitation.
Swami Medical College, Karamsad, Anand, Gujarat Signs: Vocal cord palsy.
Investigation findings
– Radiological evidence of extrinsic or intrinsic
esophageal disorders
– Abnormal esophageal manometry
– Abnormal esophageal pH recording
Diseases: Malignancy esophagus, cardiac achalasia,
strictures, infectious esophagitis, diverticulum, reflux
esophagitis, hiatus hernia, esophageal varices, caustic
ingestion, secondary neck node with unknown primary,
surveillance for second primary, penetrating trauma to
thorax to rule out esophageal injury.
Therapeutic
Foreign body
Impacted food
Dilatation of esophageal strictures, stenosis or cardiac
achalasia
Removal of benign neoplasms such as fibroma, papil-
loma, and cysts
Insertion of Soutar’s or Mousseau Barbin tube in pallia-
tive treatment of esophageal carcinoma
Tracheoesophageal puncture after total laryngectomy
Treatment of diverticulum or varices.
Fig. 6: Irregular mass occluding bronchus contrainDicationS oF eSophagoScopy
Source: Dr Rajiv Paliwal, Professor, Chest Medicine, Pramukh Absolute:
Swami Medical College, Karamsad, Anand, Gujarat
Coagulopathy.
Perforation of esophagus: Spontaneous, traumatic or
iatrogenic.
Relative contraindications: Advanced heart, liver or kidney
disease.
Contraindications of rigid esophagoscopy: In most of the
following conditions, new generations of flexible gastro-
scopes can be used successfully.
Severe trismus: It does not allow passage for esophago-
scope. Small size flexible gastroscopes can be passed
through nose.
578 Cervical spine lesions: Cervical trauma, spondylosis, facilitates passage of esophagoscope. Shoulders are at the
Pot’s spine, osteophytes, or kyphosis. edge of operation table and head rests on a special headrest
Section 8 w operative procedures and instruments or hold by an assistant.
Receding mandible. A right-handed surgeon sits on the left of the long axis of
Aneurysm of aorta: May rupture and cause fatal hemor- the patient.
The assistant, instrument table, light source, suction and
rhage. video are on right side of surgeon.
rigiD eSophagoScopy techniques (Fig. 8)
Instruments for esophagoscopy (Figs 7A to G) are described in Protection of teeth and lips: Examine the patient for neck
chapter Instruments.The size of the esophagoscope is selected as
per the age of the patient. Handle at the proximal end of esopha- stability and loose teeth or dentures. Eyes are protected
goscope indicates the direction of the bevel at the distal end. with a shield and the patient is draped. A gauze piece or
teeth guard protects the upper teeth against injury. Left
Arigid bronchoscope may be used for performing esophagoscopy hand thumb retracts the upper lip and teeth while index
but the rigid esophagoscope cannot be used for bronchoscopy. finger lifts lower teeth.
Lubrication of scope: Lubricate proper size esophagoscope
advantages with liquid paraffin or xylocaine jelly.
More amenable to therapeutic indications especially Holding of scope: Esophagoscope is held by its proximal
end in right hand and introduced into right side of mouth
removal of foreign bodies. lateral to the tongue and advanced towards the middle of
Better visualization of proximal one-third of esophagus. base of tongue.
Laryngopharynx: Esophagoscope is further advanced gently
Disadvantages by the left thumb and index finger. Identify epiglottis, endo-
General anesthesia. tracheal tube and arytenoids.
More cost and morbidity to patient. Cricopharyngeal sphincter (upper esophageal sphincter):
More complications such as dental trauma and esophageal Keep the tip of esophagoscope in midline and behind the
larynx. Lift the scope with the help of left thumb and open
perforation. the hypopharynx. Slow, gentle and sustained pressure of
Concomitant examination of stomach and intestine not the scope tip on the cricopharyngeal sphincter opens it.
Then the tip of scope is guided into the esophagus. A fine
possible. bougie or an additional dose of muscle relaxant may be
Not amenable to cases of trismus or cervical spine degen- used if needed. Advance the scope constantly seeing the
esophageal lumen.
erative diseases.
Application of too much force on upper esophageal sphincter
anesthesia is the most common cause of cervical esophageal perforation.
It is usually done under general anesthesia with endotracheal
intubation. Aortic arch and left bronchus: Indentations of aortic arch
(aortic pulsation seen and felt) and left bronchus lie about
position 25 cm from the incisors. During this time, head of the patient
Patient is placed in supine position. Head is elevated by is slightly lowered, which brings the esophageal lumen in
the line of the scope.
10–15 cm. Neck is flexed on chest. Head is extended at
atlanto-occipital joint. This position brings the axes of
mouth, pharynx and esophagus in a straight line and
a
c b
D e
F
g
Figs 7a to g: Instruments of rigid esophagoscopy. (A) Peanut Fig. 8: Procedure of esophagoscopy
foreign body grasping forceps, both jaws movable; (B) Suction
tube; (C) Cervical esophageal speculum (Laryngopharyngo-
scope), Negus pattern; (D) Esophagoscope, Jackson pattern;
(E) Suction tube; (F) Cup-shaped oval straight biopsy forceps;
and (G) Peanut foreign body grasping forceps
Cardiac end: Head and shoulders are kept below the level of endoscope and instruments (Fig. 9) 579
the table. The head, which is slightly higher than the shoul-
ders, is moved slightly to the right. The esophagoscope now Esophagoscope is available in wide range of diameter smallest
points to the left anterior superior iliac spine. Cardia has being 5.0 mm.There are separate channels for optics, suctioning
redder and more velvety or rugose mucosa. (secretions), insufflations, and instruments (for biopsy, foreign
bodies, sclerotherapy and laser ablation). Set up also includes
Withdrawing: Inspect the esophageal wall again while light source, camera and video processing unit.
withdrawing the esophagoscope.
postoperative care techniques chapter 58 w endoscopies
Features of esophageal perforation: Watch for the features The patient is usually in left lateral position or in supine
of esophageal perforation such as pain in the interscapular and gentle extension of neck with a shoulder roll.
region, surgical emphysema of neck and chest, and abrupt Lubricated scope (with xylocaine jelly) is introduced
rise of temperature.
Diet: Sips of plain water followed by usual diet may be given into the mouth through a plastic mouth block (Fig. 10)
in an uneventful esophagoscopy. and advanced into the pharynx, postcricoid region and
esophagus (Fig. 11).
complications The esophagoscope can be deflected in any direction and
Injury to lips, teeth, and pharynx. secretions can be aspirated.
Perforation of esophagus: This is the most dreaded compli- Air or water insufflation opens the lumen of esophagus and
the endoscope is advanced further.
cation and usually occurs near cricopharyngeal sphincter
(Killian’s dehiscence). Surgical emphysema develops within
an hour. It may be complicated with an abscess in retro-
pharyngeal space or mediastinum. The features of thoracic
esophageal perforation include–
Pain in the interscapular region
Surgical emphysema
Abrupt rise of temperature.
Compression of trachea: It may occur especially in children
when esophagoscope is pressed on posterior tracheal wall.
It causes obstruction to respiration and cyanosis and needs
immediate withdrawal of esophagoscope.
FLexibLe eSophagoScopy
advantages Fig. 9: Flexible esophagoscope
An outdoor procedure.
No general anesthesia. It is done under local anesthesia with
or without intravenous sedation.
Less morbidity.
It can be done in abnormalities of spine or jaw.
Gastroscope allows examination of stomach and duodenum.
Good illumination and magnification.
Accurate diagnosis of the mucosal diseases.
Disadvantages
Narrow channel limits the size of instruments and removal
of certain foreign bodies.
Foreign body cannot be retracted into the endoscope
(like rigid esophagoscope) so more chances of injuring
esophagus.
Laryngopharynx and proximal one-third esophagus
(less distensible with insufflations) may not be examined
adequately.
common indications Fig. 10: Flexible esophagoscopy. Patient’s position and plastic
Precision biopsies mouth block in mouth
Removal of small foreign bodies or benign tumors
Dilatation of webs or strictures
Injection of sclerosing agents in bleeding varices.
Section 8 w operative procedures and instruments580
Fig. 11: Flexible esophagoscopy. Note the biopsy forceps in the hand of assistant
clinical highlights
1. tracheobronchial tree and larynx: Rate of topical absorption is highest.
2. objective piece of operative microscope: 400 mm focal length of objective piece of operative microscope is usually
used for microlaryngoscopy.
3. Flexible bronchoscopy: It offers visions of segmental bronchi and the upper lobe bronchi, which are beyond the reach
of rigid bronchoscopes.
4. rigid bronchoscopy: It is superior in taking biopsy and culture specimens, removing foreign bodies and in surgical
intervention such as dilatation.
5. esophagoscopy: Application of too much force on upper esophageal sphincter (UES) is the most common cause of
cervical esophageal perforation.
6. esophageal perforation:
a. Features: Fever after esophagoscopy.
b. Diagnosis: Swallow study confirms diagnosis.
c. treatment: Early intervention to repair is most desirable. Drain the perforation to prevent complications.
Further reaDing
1. George A, Sinha V. Balloon and bougie dilation of benign esophageal strictures. Indian J Otolaryngol Head Neck Surg. 2005;57:196-8.
2. Ghosh SK, Chattopadhyay S, Bora H, et al. Microlaryngoscopy study of 100 cases of hoarseness of voice. Indian J Otolaryngol Head Neck
Surg. 2001;53:270-2.
3. Khanna S, Khanna S. Management of benign oesophageal strictures in children. Indian J Otolaryngol Head Neck Surg. 2008;60:218-22.
4. Phaniendra Kumar V, Srinivasa MM, Ravikanth S, et al. Phonomicrosurgery for benign vocal fold lesions-our experience. Indian J
Otolaryngol Head Neck Surg. 2003;55:184-6.
5. Sharma K, Sachdeva R, Duggal KK, et al. Direct laryngoscopic observations in progressive hoarseness of voice. Indian J Otolaryngol
Head Neck Surg. 2006;58:364-7.
6. Shivakumar AM, Naik AS, Prashanth KB, et al. Foreign bodies in upper digestive tract. Indian J Otolaryngol Head Neck Surg. 2006;58:63-8.
7. Sreenath J, Mahendrakar V. Management of tracheobronchial foreign bodies-a retrospective analysis. Indian J Otolaryngol Head Neck
Surg.2002;54:127-31.
59 Instruments
Misery is truly a gift of God. I believe it is a symbol of His compassion. It is idle to expect that dangers and difficulties will not come.
They are bound to come. But, for a devotee of God they will pass away from under feet like water.
—Holy Mother Sarada Devi
points of focus
¯ IntroDuctIon ¯ ADenotonSIllectoMY
¯ opD InStruMentS
Boyle-Davis mouth Gag, Tonsil Holding Forceps,
Dressing Forceps, Ear Speculum, Otoscope, Tuning Fork, Tonsil Knife, Tonsil Dissector and Anterior pillar
Barany Noise Box, Aural Syringe, Blunt probe, Laryngeal retractor, Tonsil Scissors, Negus Artery Forceps, Tonsil
mirror, Thudicum Nasal Speculum, Lack’s L-shaped Needle, Yankauer’s Suction Tube, Eve’s Tonsil Snare,
Tongue Depressor, postnasal mirror, Jobson-Horn Conchotome, Draffin’s Bipod, St. Clair Thomson’s
probe with ring curette, Siegel’s pneumatic Speculum, Adenoid curette With Guard, Tonsil Dissection Forceps
Eustachian catheter and politzer’s Bag. With Teeth (Waugh’s), Tonsil Artery Forceps, Negus
Knot Tyer
¯ MAStoID AnD eAr-MIcroSurGerY
¯ IncISIon AnD DrAInAGe of QuInSY
Endaural Speculum, myringotome, mastoid Self-
retaining retractors, Lempert’s Endaural retractor, peritonsillar (Quinsy) Abscess Forceps
mastoid Suction Tips, mastoid Gouges, mastoid curette ¯ enDoScopeS
(Scoop), Farabeuf’s periosteal Elevator, macewen’s
curette and cell Seeker, crocodile (Alligator) Scissors comparison between Two Types of Illumination
and Forceps, microsurgery Instruments (Zoellner) (Jackson and Negus)
¯ AntruM puncture Laryngoscopes: Direct Laryngoscope, Laryngoscopes for
microlaryngoscopy and Surgery:
Lichtwitz Trocar and cannula, Higginson’s Syringe
¯ InferIor MeAtAl AntroStoMY Bronchoscope
Tilley's Harpoon, Tilley' Antral Burr, rose' Sinus Esophagoscope
Douching cannula
Endoscope and Instruments
¯ nASAl frActure reDuctIon forcepS ¯ trAcHeoStoMY
Walsham’s Forceps, Asch’s Septum Forceps Tracheal Dilator, Tracheal Hook (Blunt and Sharp)
¯ nASAl SeptAl AnD SInuS SurGerY
Types of Tracheostomy Tubes
Endoscopic Sinus Surgery Instruments: Hopkins
Telescope/Sinuscope, Bloberley Forceps, punches, Fuller’s Bivalved Tracheostomy Tube
Bone Forceps, chisels, Heymann Turbinectomy
Scissors, Elevators, Nasal Speculum, mattel, Nasal chevalier Jackson’s Tracheostomy Tube
Gouges, periosteum Elevator, Luc’s Forceps,
Ballenger’s Swivel Knife Nonmetallic Tracheostomy Tubes: cuffed tracheostomy
Tube, cuffed Suction Aid Tracheostomy Tube
¯ MoutH GAGS AnD retrActorS
Size of Tracheostomy Tube
Jenning’s mouth Gag, Doyen’s mouth Gag, cheek ¯ AIrwAY DevIceS
retractor, Hajek Lip retractor
Nasopharyngeal Airway, Oropharyngeal Airway, Laryngeal
mask Airway (LmA), Endotracheal Tubes
582 IntroDuctIon
There is vast number of ENT instruments used for diagnostic,
therapeutic and surgical purposes. It is beyond the scope of
this book to discuss each and every instrument. The figures
show quite good number of instruments but the description
covers only frequently asked instruments. For the further details
regarding the method of use and indications, the reader should
refer to the related chapters such as History and Examination
and section of Operations.
Section 8 w operative procedures and Instruments opD InStruMentS figs 1A to l: OpD ear instruments. (A) Jansen dressing for-
Figures 1A to L and 2A to J show OPD instruments. For the ceps bayonet shaped; (B) plastic ear speculum; (c) Hart-
related details, see chapters of “Symptoms and Examination” mann ear speculum; (D) Boucheron ear speculum; (E) Heine
of respective sections. Otoscope with plastic ear specula; (F) Tuning fork; (G) Bil-
Dressing forceps (Figs 1 A, I and J): Tilley’s dressing forceps leau ear loop; (H) Barany noise box with soft rubber; (I) Lucae
ear dressing forceps; (J) Troeltsch dressing forceps angular;
has a box joint. Its bayonet-shaped or bent at an obtuse (K) Ear syringe; (L) Weber-Loch ear curette
angle prevents the hand of the surgeon from obstructing Source: Karl Storz, Germany
the line of vision. Hartmann’s dressing forceps is similar to
Tilley’s forceps and has a screw joint and the serrated and Thudicum nasal speculum (Fig. 2F): Thudicum nasal
grooved jaws. Wilde’s dressing forceps acts on spring action. speculum consists of U-shaped metal spring with two
Uses: They are used for nasal packing, ear dressing and blades at its ends. The size of the nasal speculum should
be chosen according to the age of patient and size of the
removal of foreign bodies. nose. A Thudicum or Vienna type of nasal speculum is held
Ear speculum (Figs 1B to D): This cone-shaped speculum has in the left hand, assists in widening the vestibule. For the
method of examination, see chapter“Nasal Symptoms and
tapered end that is inserted into the cartilaginous portion of Examination” in section “Nose and Paranasal Sinuses”.
the external auditory canal (EAC) after retracting the pinna. Uses: They are used for examination and during surgery
The black or dull finished speculums are used in operations of the nose.
and prevent reflection of light. Various sizes and shapes of
the ear speculums are available, which suit different sizes Lack’s L-shaped tongue depressor (Fig. 2J): One blade of Lack’s
of the ear canal. The use of the largest ear speculum that tongue depressor is slightly bent at the end. The bent end is
can easily enter the canal is safe and provides better view. used for holding the depressor and supports the little finger
Use: It is used for examination and operations of the of the examiner. The other blade depresses the tongue
and is used like a lever to depress anterior two-third of the
EAC, tympanic membrane and middle ear. tongue with the fulcrum over the lower teeth.
Otoscope (Fig. 1E): It has its own illumination, and the source Caution: Touching of the posterior one-third of the
tongue usually leads to the gag reflex and not tolerated
of light that is housed in its handle. It also provides magni- by the patient.
fication. Some of the otoscopes have Siegel’s speculum. Uses: It is used for examining the oral cavity and the
Use: It helps in examining the EAC and tympanic pharynx. In addition to the depressing of tongue, it can
also be used for:
membrane. It is especially useful in examining the ears – Squeezing the tonsil
and nose of infants and bedridden patients. – Retraction of cheek
Tuning fork (Fig. 1F): For details of tuning fork tests, see – Test for gag reflex
chapter “Hearing Evaluation”. – To check nasal air blast
Use: They are used for Rinne, Weber and other hearing – Spatula test for suspected case of tetanus
tests. – Posterior rhinoscopy examination
Barany noise box (Fig. 1H): For further details, see chapter – Checking out for loose teeth
“Hearing Evaluation”. – Intraoral surgical procedure
Use: It is used for masking purposes during the tuning – Checking postnasal bleeding.
fork hearing tests.
Aural syringe (Fig. 1K): This metal syringe consists of a Postnasal mirror: Mirror is smaller than laryngeal mirror and
cylinder with a well-fitting piston and a nozzle. For details the shaft is bayonet-shaped.
of ear syringing, see chapter “Diseases of External Ear”. Use: It is used for examining the nasopharynx and poste-
Use: It is used for ear syringing to remove EAC wax and rior part of nasal cavity. See chapter “Nasal Symptoms
foreign bodies. and Examination”in section“Nose and Paranasal Sinuses”.
Blunt probe:
Use: It is used for palpation of polyp, growths and swell- The posterior rhinoscopy mirror is smaller and its shaft is
ings in the ear canal as well as nasal cavity. bayonet-shaped, while the shaft of the laryngeal mirror is
Laryngeal mirror (Fig. 2A): The shaft of the laryngeal mirror is straight.
straight. It is available in various sizes from 6–30 mm diam-
eter. See chapter “Laryngeal Symptoms and Examination”
in section larynx, trachea and bronchus.
Use: It is used for the indirect examination of oropharynx,
laryngopharynx and larynx.
– Topical ear medicines: Pushing of medicines through 583
the central perforation of tympanic membrane.
figs 2A to J: Some of the routinely used OpD ear, nose, and chapter 59 w Instruments
throat instruments. (A) Laryngeal mirror; (B) Otoscope; (c) Tun- Eustachian catheter and Politzer’s bag (Figs 5A to E):
ing fork; (D) Ear vectis and curette; (E) Jobson Horne probe with Eustachian catheter is a 12–15 cm metal cannula. It has
round serrated end applicator and curette end; (F) Thudicum na- a ring at its base that indicates the direction of its curved
sal speculum; (G) Ear speculum; (H) Bayonet-shaped ear dress- tip. It looks similar to the antral washing cannula, in which
ing forceps; (I) Straight tongue depressor; (J) L-shaped tongue opening is not at the tip but a little proximal to it. An olive-
depressor shaped tip of the Politzer’s bag is introduced into the nose.
Uses:
– Politzer test and Eustachian tube catheterization
for testing the functioning of Eustachian tube. For
further details, see chapter“Disorders of Eustachian
Tube”.
– To inflate the middle ear
– To instill medicines into middle ear
– To remove foreign body from the nose
– For suctioning the secretions and discharge
MAStoID AnD eAr MIcroSurGerY
Figures 6A to E show speculum, retractors and suction cannula.
Figures 7A to H and 8A to G show bone cutting instruments.
Jobson-Horne probe with ring curette (Figs 2E and 3): It has AB
two ends: round serrated end applicator and curette end.
Use: One end of the Jobson-Horne’s probe is used figs 4A and B: Siegel’s examination. mobility of tympanic
for applying cotton to clean the ear of discharge. The membrane is tested by alternately increasing and decreasing
other end (ring curette) is used to remove the wax and pressure in the external auditory canal. (A) method of Siegel’s
foreign body. examination; (B) Siegel’s pneumatic speculum fitted with a con-
vex lens and attached rubber bulb through plastic tubing
Siegel’s pneumatic speculum: It is (Figs 4A and B) fitted with a
convex lens and is attached to a rubber bulb through plastic
tubing. The rubber bulb assists in alternately increasing and
decreasing pressure in the EAC. Its convex lens provides
magnification.
Uses:
– Mobility of tympanic membrane: It is tested with
Siegel’s speculum.
– Fistula test: It is for labyrinthine fistula (see chapter
Evaluation of Vertigo).
– Aural toilet: Suction of middle ear secretions in cases
of acute and chronic suppurative otitis media.
B
A cD e
fig. 3: Jobson Horne’s probe. Applying cotton to clean the ear figs 5A to e: Eustachian tube instruments. (A) politzer air bag
of discharge while the other end (ring curette) is used to remove 8 ounce capacity; (B) metal connector Eustachian catheter to
the wax and foreign body politzer air bag; (c) Nasal tip for use with politzer air bag; (D)
Hartmann Eustachian catheter; (E) Soft rubber air bag (2.5
ounce capacity) for use with Eustachian catheter
Source: Karl Storz, Germany
584 Figures 9A to I show elevators and suction cannula. Figures
10 A to F show ear snare and micro forceps. For details of the
Section 8 w operative procedures and Instruments operations and more instruments, see chapter“Middle Ear and figs 6A to e: Ear surgery instruments retractors. (A) Hartmann
Mastoid Surgeries”. speculum; (B) Wullstein retractor; (c) plester retractor 2 x 2
Endaural speculum (Fig. 6A): There are many types of prongs; (D) plester retractors with biprong blade and solid blade
for left and right side; (E) Ferguson suction tube with finger cut-
endaural speculum including Lempert’s. This curved off and stylet
speculum is similar to Vienna model. Source: Karl Storz, Germany
Use: It spreads open the meatus and is used when giving
figs 7A to H: Ear surgery bone cutting instruments. (A) cot-
local injection or making an endaural incision. tle mallet; (B) Trautmann mastoid chisel; (c) Trautmann mastoid
Myringotome: gauge; (D) Lucae mallet; (E) Spratt mastoid curette; (F) House
curette; (G) Beyer rongeur light curved jaws; (H) Kerrison ron-
Use: For puncturing tympanic membrane and placing geur
grommets. Source: Karl Storz, Germany
Mastoid self-retaining retractors (Figs 6B to D): There are figs 8A to G: Ear surgery instruments, electric motor and burrs.
many types of mastoid retractors including Mollison’s and (A) Oval burr; (B) Oblong burr; (c) Standard burr; (D) Bone en-
Jansen’s. The catch prevents its closure and the blades hold gine with hand held micromotor; (E) Intra hand piece straight and
apart the edges of the incision. angled; (F) Slip joint hand piece straight and angled; (G) Bone
Uses: engine with micromotor
– Mastoidectomy: They retract soft tissues after inci- Source: Karl Storz, Germany
sion and elevation of flaps. The pressure on the
edges of the incision provides hemostasis.
– Other operations: This self-retaining retractor may
be used in other surgeries, such as laryngofissure,
craniotomy, burr-holing and external ethmoidec-
tomy.
Lempert’s endaural retractor: It has three blades. The two
lateral blades retract the flaps. The third central blade with
holes retracts the temporalis muscle superiorly. The central
blade with its hole is fixed to the body of the retractor.
Use: It is specifically used in the endaural approach
mastoidectomy.
Mastoid suction tips (Figs 6E and 9C to F): This bent cannula
has an obtuse angle and a hole that can be used to regulate
the force of suction. The hole can be closed by placing a
finger tip on it. Fine suction tips are used for microsurgery.
Use: Suction of blood, secretions, irrigation water and
bone dust.
Mastoid gouges (Figs 7C and 15D): They are of various sizes
and have a concave edge and rounded margins.The electrical
drill and burrs (Figs 8 A to G) are replacing the use of gouges.
Uses:
– Mastoidectomy: They are used to remove bone in
mastoid surgery.
– Caldwell-Luc operation: It is also used for canine
fossa antrostomy for opening the maxillary antrum.
– Exostosis: Excision of exostosis in the EAC.
Mastoid curette (scoop) (Figs 7E and F): There are many types
of mastoid curette including Lempert’s.
Use: It removes bony septa and granulations in mastoid
surgery.
Farabeuf’s periosteal elevator (Fig. 9H)
Use: It is used for elevation of periosteum from the
mastoid cortex in mastoidectomy.
Macewen’s curette and cell seeker: It has two ends which have
different functions.
Use: One end (seeker) explores the air cells and mastoid
antrum. Other end curettes the intervening septa and
granulations in mastoid surgery.
Crocodile (alligator) scissors and forceps (Figs 10A to F): These
thin and delicate forceps have crocodile or alligator jaws
type tips and are used for microsurgery of the ear.
585
B
A
c
figs 9A to I: Ear surgery instruments, elevators and suctions. figs 11A to c: Antrum puncture instruments. (A) Lichtwitz chapter 59 w Instruments
trocar; (B) cannula; (c) Higginson’s syringe
(A) Jansen elevator; (B) plester elevator; (c) plester suction tube
with finger cut-off and stylet; (D) Zoellner suction tube with finger Lichtwitz trocar and cannula: It perforates the lateral wall of
cut-off; (E) Fisch adaptor for suction cannula with finger cut-off inferior meatus. This area is easily accessible and safe region.
luer cone; (F) Fisch suction irrigator; (G) Lempert elevator; (H) After piercing the nasoantral wall, trocar is removed.
Use: It is used for proof puncture (antral lavage).
Farabeuf’s elevator; (I) Fisch elevator
Higginson’s syringe:
Source: Karl Storz, Germany Use: It is used in irrigating the maxillary antrum with
normal saline.
InferIor MeAtAl AntroStoMY
Tilley’s harpoon
Use: It is used for intranasal antrostomy in the inferior
meatus.
Advantage: It removes the bony chips when it is with-
drawn. So the bony chips do not fall in the sinus cavity.
Tilley’s antral burr
Use: It enlarges and smoothens the hole made by
harpoon in intranasal inferior meatal antrostomy.
Rose’s sinus douching cannula: The hook outside indicates
the direction of the tip.
Use: It is used for the irrigation of maxillary sinus
through the nasoantral inferior meatus window after
intranasal antrostomy or Caldwell-Luc operation.
figs 10A to f: Ear micro-forceps and snares. (A) Hartmann ear nASAl frActure reDuctIon forcepS
forceps serrated and cupped jaws; (B) Wilde ear snare bayonet (fIGS 12A AnD B)
type; (C) Krause ear snare; (D) Wullstein very fine ear forceps For other related details, see chapter “Maxillofacial Trauma”.
serrated and cupped jaws; (E) House-Dieter very fine malleus Walsham’s forceps (Fig. 12A): Rubber tubing may be used
nipper; (F) Bellucci delicate scissors
Source: Karl Storz, Germany to cover one blade to protect the skin of the external nose.
Use: They are used for the disimpaction and reduction
Microsurgery instruments (Zoellner): This set of ear microsur-
gery instruments are bent at a right angle and have a handle of the fractures of nasal bones.
to hold them between the thumb and fingers. The black or Asch’s septum forceps (Fig. 12B): The forceps are bent at an
dull finish prevents the glare of light under the microscope.
obtuse angle. When they are closed, there remains a gap
AntruM puncture between the blades that prevent the crushing of the nasal
Figures 11A to C show the instruments used for antrum punc- septum.
ture. For the detailed procedure and indications, see chapter Use: They are used for reducing fractures of nasal
“Operations of Nose and Paranasal Sinuses”.
septum. It lifts the nasal septum forwards.
nASAl SeptAl AnD SInuS SurGerY
Figures 13A to G and 14A to P shows instruments of endoscopic
sinus surgery. Figures 15A to O and 16A to J show instruments
of nasal and septal surgeries. See chapter “Operations of Nose
and Paranasal Sinuses” for the related details.
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Mohan Bansal - Diseases of Ear, Nose and Throat (2013)
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