ENT Ear Nose Throat

Otologic Surgery-Anatomy

External ear- Auricle (pinna) Concentrates sound waves and conducts them into the external auditory canal Flexible cartilage covered with thick skin One on each side of head helps judge direction of sounds Shape of auricle helps differentiate between sounds in front or back

External auditory canal S-shaped pathway about 2.5 cm long Made up of bone and cartilage, covered by soft, sensitive skin Cerumen- waxy substance Protects and lubricates canal Secreted by sebaceous glands in the distal third of the canal Helps trap foreign materials and reduce bacterial levels

Tympanic Membrane (eardrum) Comprised of three layers Outer layer- epithelium Middle layer- fibrous connective tissue Inner layer- mucous membrane Is disc shaped, concave, translucent gray, with a diameter of about 1 cm Protects the middle ear

Middle ear Filled with air from the nasopharynx via the Eustachian tube Communicates with the mastoid air cells of the temporal bone

Middle ear

Middle ear Mucous membrane of the middle ear is continuous with that of the pharynx and mastoid cells, making it possible for infection to travel to the middle ear (otitis media) and the mastoid cells (mastoiditis)

Middle ear Ossicles- a chain of 3 tiny, moveable bones that extend across the middle ear, from the tympanic membrane to the oval window Malleus (hammer) Incus (anvil) Stapes (stirrup) Moveable joints allow the ossicles to transmit sound across the middle ear

Conduction Tympanic membrane Malleus Incus Stapes Oval window Fluid of cochlea Round Window Hair Cells of the organ of Corti

Middle ear Oval window- an oval shaped aperture in the wall of the middle ear leading to the inner ear. The footplate of the Stapes vibrates in the oval window, transmitting sound waves to the cochlea.

Middle ear Round window- below the oval window. Round opening in the medial wall of the middle ear leading into the cochlea and covered by a membrane called the secondary tympanic membrane

Inner ear (labyrinth) Bony labyrinth Membranous labyrinth

Inner ear (labyrinth) Bony labyrinth- filled with watery fluid (perilymph) that surrounds and bathes the membranous labyrinth 3 divisions Cochlea Vestibule Semicircular canals

Inner ear (labyrinth) Cochlea- tubular shaped, resembling a snail shell Organ of Corti- neural end organ for hearing Neuroepithelium- projects thousands of hair cells that convert the wave motion into electrochemical impulses Connected to the brain by the 8th cranial nerve (vestibulocochlear or acoustic)

Inner ear (labyrinth) Vestibule-contains 2 sacs, utricle and saccule, which are gravity oriented and concerned with static equilibrium Semicircular canals- 3- lateral, superior, and posterior canals, at approximate right angles to each other Controls equilibrium during movement

Inner ear (labyrinth) Membranous labyrinth- within it lie four (4) structures: the cochlear duct, utricle, saccule, and the semicircular ducts Endolymph bathes and nourishes the sensory cells contained within the membranous labyrinth

Conduction Tympanic membrane Malleus Incus Stapes Oval window Fluid of cochlea Round Window Hair Cells of the organ of Corti

Ménière’s disease Recurrent and usually progressive group of symptoms including: Progressive deafness Ringing in the ears Dizziness Sensation of fullness or pressure in the ears Attacks occur suddenly and may last as long as 24 hours

Ménière’s disease Normal Membranous Labyrinth Dilated Membranous Labyrinth in Ménière’s disease (Hydrops)

Ménière’s disease When one ear is affected, the other will also become involved in approximately 50% of cases Etiology is unknown, but edema of the membranous labyrinth has been found in autopsies TX- bed rest, antihistamines, sedatives, discontinuation of smoking, and, rarely, surgery

Considerations Gloves must be powder free to prevent granuloma formation, which could lead to irreversible hearing loss Operating microscope is used routinely, and handles or a drape will be needed

Considerations Pass instruments in a manner to allow the surgeon to remain focused on the operative site Instruments are delicate, and must be handled carefully to avoid damage

Considerations When using a burr to remove bone constant irrigation is needed to combat heat buildup and bone dust accumulation

Considerations Multiple suction tips must be available, as they are so fine they clog frequently A nerve stimulator should be available Hemostasis may be accomplished with epinephrine, gelfoam or bone wax

Anesthesia Local anesthesia may be used for minor procedures on the external ear, or for procedures in which the doctor wants to test the patients hearing during the procedure

Anesthesia General anesthesia is used to prevent patient movement on procedures involving the fine structures of the middle or inner ear

Anesthesia In the absence of inflammation the mastoid bone lacks sensation, except for the outer periosteum, so a local anesthetic may be used

Positioning Patient should be supine with the operative ear up Dependent ear should be protected from pressure with a donut or similar headrest

Prep Hair may be shaved or clipped if necessary, and/or plastic drapes may keep the field free from hair Prep the auricle and periauricular skin Meatus may be prepped with a swab if the eardrum is not perforated

Draping Should be lint free to prevent granuloma formation Plastic aperture drapes are common, and may be placed before or after the prep Triangle off with 3 towels, and a fenestrated drape may be placed Split sheets may also be utilized

Incisional approaches Endaural- incision is made near the meatus Offers direct access to the canal and tympanic membrane, or for stapes surgery

Incisional approaches Transcanal- incision is made in the tympanic membrane, through the canal For surgery on the tympanic membrane or the ossicles

Incisional approaches Postauricular- incision is made behind the ear, following the posterior auricular skin fold Used for procedures on the mastoid, middle, and inner ear

Surgical interventions

Myringotomy Incision of the tympanic membrane, usually with placement of pressure equalization (PE) tubes Performed to treat acute otitis media, when the exudate does not respond to antibiotic therapy Common pediatric problem

Myringotomy There are a variety of PE tubes to choose from, depending on the length of time the doctor wants them to stay in.

Myringotomy Care must be taken to avoid getting water in the ears while the tubes are in place Myringotomy knife, alligator forceps, and microscope Once the tube fall out, the incision usually heals

Tympanoplasty Surgical repair of the tympanic membrane Usually for perforation of the ear drum resulting from direct injury, blow to the ear, tears from temporal bone fractures, and lightning injury

Tympanoplasty

Tympanoplasty Most common serious ear injury necessitating surgical intervention Conductive hearing loss, as it may disturb ossicular continuity Repaired using a graft (dried temporalis fascia or synthetic)

Mastoidectomy Removal of diseased bone of the mastoid process, along with the cholesteatoma present in the middle ear and the mastoid Cholesteatoma- a cystic mass composed of epithelial cells and cholesterol that is found in the middle ear.

Mastoidectomy

Mastoidectomy Cholesteatoma- Occurs as a congenital defect or as a serious complication of otitis media The mass may occlude the middle ear, or enzymes produced by it may destroy the adjacent bones, including the ossicles

Mastoidectomy General anesthesia usually, but can use local Postauricular or endaural incision Use a burr to remove diseased bone Simple mastoidectomy- removal of the air cells

Mastoidectomy Modified radical mastoidectomy- removal of the air cells and the wall of the external ear canal, preserving the ossicles

Mastoidectomy Radical mastoidectomy- removal of the mastoid air cells, along with the tympanic membrane, malleus and the incus. Stapes usually remains in place, and is covered with a temporalis fascia graft

Stapedectomy Removal of the stapes for otosclerosis, and replacement with a prosthesis to restore ossicular continuity and alleviate conductive hearing loss

Removal of Acoustic Neuroma Benign tumor of the acoustic nerve Symptoms may include tinnitus, progressive hearing loss, headache, facial numbness, dizziness Typically slow growing

Removal of Acoustic Neuroma Proximity to the cranial nerves and the brainstem make them dangerous intracranial lesions Ideal TX is total removal of the tumor Postauricular incision

Cochlear implantation Implantation of an electrode into the cochlea to stimulate remaining nerves in an otherwise profoundly deaf patient (with bilateral loss)

Cochlear implantation Candidates include adults who became profoundly deaf after acquiring language skills and children under the age of 18 Electrode implanted in the cochlea

Rhinologic and Sinus surgery More ENT  Rhinologic and Sinus surgery

Anatomy

External Nares- 2 external openings through which air may enter and exit Separated by the columella, which is formed by the skin and mucous membranes Vestibule- anterior portion (chamber) of the nose Internal hairs help prevent coarse particles from entering

External Septum- divides the nose into 2 chambers Lined by mucous membrane Made up of cartilage anteriorly and bone posteriorly

Internal Extends to the nasopharynx Communicates with the ear via the eustachian tube Communicates with the conjunctiva via the nasolacrimal duct Communicates with the paranasal sinuses via the middle and superior meatus'

Sinuses Maxillary- In the maxillary bone Communicates with the middle meatus of the nasal cavity Antrum- any nearly closed cavity or chamber, especially in a bone

Sinuses Frontal- Irregular cavity in the frontal bone on each side of the midline above the nasal bridge A duct carries secretions to the upper part of the nasal cavity

Sinuses Ethmoid- located in the ethmoid bone Sphenoid- Occupies the body of the sphenoid bone

Sinuses All communicate with the nasal cavity They lighten the skull, being lighter than dense bone, and act as a resonating chamber for voice

Internal Hard and soft palates divide the nasal cavity from the oral cavity Ethmoid bone separates the nasal cavity from the cranial cavity

Internal Turbinates (conchae)- scroll like bones covered with vascular mucosa (superior, middle and inferior) Increase the surface area of the nose

Internal Blood supply- external and internal carotid arteries Olfactory epithelium- superior region of the cavity, above the superior turbinate Nerve supply- sense of smell from first cranial nerve (olfactory) and sensory nerve supply from the fifth (trigeminal) cranial nerve

Considerations Paranasal sinuses and tissues underlying mucosa are sterile. Instruments should be sterile, even though the nasal cavity is a contaminated area

Considerations Surgeons use a headlight Awake patients feel the doctor working and hear what is being said

Considerations Nasal packing is inserted at the end of most nasal procedures, but not following sinus surgery Usually made up of gauze impregnated with antibiotic ointment Because of the nasal pack the patient may have difficulty swallowing (vacuum)

Considerations Moustache dressing may be used when drainage is desirable Forceful nose blowing should be avoided post-op Head of bed should be elevated post-op to facilitate breathing Ice pack may be used post-op to reduce swelling

Anesthesia Local, local with sedation, or general (when entering sinuses) If general is used a throat pack may be placed to prevent aspiration of blood Local anesthetic is sometimes referred to as a nasal prep

Nasal Prep Nasal speculum, bayonet forceps and fine scissors Topical 4% cocaine, sprayed or on swabs or cottonoids, provides vasoconstriction and topical anesthesia

Nasal Prep Local anesthetic (lidocaine with epi) injected Scrub sets up a nasal prep stand on a separate table, to include all the necessary items. Doctor performs the nasal prep before he scrubs

Positioning & Prepping Supine or fowlers Positioned for comfort (awake patients) Omit prep or prep only nose and face (externally)

Draping Head drape and split sheet Patient under general should have eyes taped closed

Surgical interventions Septoplasty or submucous resection of the septum (SMR)

Surgical interventions Septoplasty or submucous resection of the septum (SMR)- straightening of the cartilaginous or bony portions of the septum When the septum is deformed, fractured, or injured, normal respiratory and nasal function may be impaired

Surgical interventions Septoplasty or submucous resection of the septum Deviations may block the meatus and compress the middle turbinate, resulting in an obstruction of the sinus opening Septal deviations tend to produce sinus disease and nasal polyps

Surgical interventions Septoplasty or submucous resection of the septum Performed to establish an adequate partition, providing a clear airway through both the internal and external cavities of the nose

Surgical interventions Rhinoplasty- elective cosmetic procedure to improve the appearance of the nose

Surgical interventions Repair of a nasal fracture- under local anesthetic insert a Boies elevator into the nostril and mold nose back into place. Nasal packing or splints may be used.

Surgical interventions Epistaxis or Rhinorrhagia- nosebleed Direct pressure usually controls the problem Chronic treated with packing, cauterization, or ligation

Endoscopic Sinus Surgery Direct visualization with an endoscope into the sinus for drainage, polyps, etc.

Endoscopic Sinus Surgery Instruments are placed into nose alongside the endoscope Scopes have different directions of view (0, 30, 70, 90, and 120)

Computer Assisted Endoscopic Sinus Surgery Uses computerized planning tools and an intraoperative navigation system http://www.josephbjacobs.com/surgery.html

Sinus Surgery Ethmoidectomy- usually performed to treat chronic inflammatory sinus disease or polyps Remove the diseased portion of the middle turbinate, ethmoid sinus cells, and diseased tissue in the nasal fossa

Sinus Surgery Ethmoidectomy Reduces the many-celled ethmoid into one large cavity to ensure adequate drainage and aeration Usually performed endoscopically, but may be performed intranasally, externally, or transantrally

Sinus Surgery Frontal sinus trephination- creation of a hole in the frontal sinus to drain pus or fluid accumulation Performed to treat the symptoms of frontal sinusitis, which may include fever and headaches

Sinus Surgery Frontal sinus trephination Incision made medially below the eyebrow A catheter may be placed to act as a drain and a medium in which to irrigate the sinus until the disease resolves

Sinus Surgery Sphenoidotomy- creation of an opening into one or both of the sphenoidal sinuses. Usually performed endoscopically, but may be performed through an intranasal or external approach

Sinus Surgery Nasal polypectomy- removal of polyps from the nasal cavity Polyps may obstruct air and make breathing difficult

Sinus Surgery Caldwell-Luc with radical antrostomy Radical antrostomy establishes a large opening into the wall of the inferior meatus of the nose, allowing for adequate drainage and aeration

Sinus Surgery Caldwell-Luc with radical antrostomy

Sinus Surgery Caldwell-Luc with radical antrostomy Incision into the canine fossa of the upper jaw and exposure of the nasal antrum for removal of bony and diseased portions of the antral wall and contents of sinus

Laryngolic Surgery and Head and Neck surgery Even More ENT  Laryngolic Surgery and Head and Neck surgery

Anatomy Oral cavity Mouth formed by cheeks, hard and soft palates, and the tongue Maxilla- upper jaw Mandible- lower jaw

Anatomy Oral cavity Temporomandibular joint- one of two joints connecting the mandible of the jaw to the temporal bone of the skull. It is a combined hinge and gliding joint

Anatomy Oral cavity Buccal Cavity- portion of the mouth outside the teeth Lingual cavity- portion of the mouth inside the teeth Hard palate- formed by the maxilla and palatine bones

Anatomy Teeth Deciduous- aka baby teeth Permanent 32 total 20 by age 2 ½ Permanent 32 total

Anatomy Oral cavity Soft palate- arch shaped muscular partition between the oropharynx and laryngopharynx Uvula- fingerlike projection at the posterior portion of the soft palate

Anatomy Pharynx Extends from the posterior of the nose to the esophagus and larynx

Anatomy Pharynx Serves as a channel for both the digestive and respiratory systems Approximately 13 cm long, is wider above and narrower below Lie anterior to the cervical vertebrae, and posterior to the oral and nasal cavities Composed of muscular and fibrous membranes, lined with a mucous membrane

Anatomy Pharynx Divided into 3 sections- Nasopharynx- uppermost, behind nasal cavity Adenoids (pharyngeal tonsils) are suspended from the roof

Anatomy Pharynx Divided into 3 sections Oropharynx- middle section, behind the oral cavity Palatine tonsils are located one on each side- can become inflamed (tonsillitis) Lingual tonsils on each side, near base of the tongue

Anatomy Pharynx Divided into 3 sections Laryngopharynx (hypopharynx)- lowest section, from the level of the hyoid bone to the larynx anteriorly and esophagus posteriorly

Anatomy Larynx- Situated between the base of the tongue and the trachea Cartilaginous box, situated in front of the 4th, 5th and 6th cervical vertebrae

Anatomy Larynx- Thyroid cartilage (Adam’s apple) Epiglottis- leaf shaped elastic fibrous membrane which closes off the larynx to protect it during swallowing Cricoid cartilage- complete cartilaginous ring that resembles a signet ring- lies beneath the thyroid cartilage and supports the airway

Anatomy Larynx- Has 3 main functions To serve as a passageway for air As a valve to close off the air passages from the digestive system As a voice box (aka) which sound and speech depend on to a degree

Anatomy Larynx- Mucous lining of the larynx blends with the fibrous tissue to form two folds on each side of the larynx. False cords- upper set of folds True cords- lower set of folds. Known as the true vocal cords, and are primarily concerned with the speaking voice and protection of the lower respiratory channels from food and foreign bodies

Anatomy Larynx- Mucous lining of the larynx blends with the fibrous tissue to form two folds on each side of the larynx. Glottis- triangular space between the vocal folds

Anatomy Trachea Cartilaginous tube, 15 cm in length, 2-2.5 cm in diameter Lies anterior to the esophagus, enters the superior mediastinum, then divides into the right and left bronchi Composed of a series of C-shaped rings of hyaline cartilage

Anatomy Salivary glands- 3 pairs- sublingual, submandibular, and parotid Communicate via ducts with the mouth and produce saliva, which moistens the mouth and initiates the digestion of carbohydrates

Anatomy Salivary glands Sublingual- beneath the mucous membrane in the floor of the mouth at the side of the tongue Blood supply- submental arteries Nerve supply- sympathetic nerves

Anatomy Salivary glands Submandibular- lies partly above and partly below the posterior half of the base of the mandible Closely associated with the lingual veins and the lingual and hypoglossal nerves

Anatomy Salivary glands Submandibular- lies partly above and partly below the posterior half of the base of the mandible Facial artery lies on its posterior border Its duct, Wharton’s duct, runs superficially beneath the mucosa of the floor of the mouth and enters the oral cavity behind the central incisors

Anatomy Salivary glands Parotid- lies below the zygomatic arch in front of the mastoid process and behind the ramus (branch) of the mandible Is the largest of the salivary glands Is enclosed in fascia and attached to surrounding muscles

Anatomy Salivary glands Parotid- Is divided into 2 divisions, a superficial portion and a deep portion, by the facial nerve (VII) Parotid duct (Stensen’s duct) Superficial temporal artery and small branches of the external carotid artery arise in the gland Injury to the facial nerve (VII) is a surgical hazard

Considerations Instrumentation varies widely between intraoral and extraoral procedures, and endoscopic procedures Headlights are used routinely by the surgeon

Anesthesia General or local (with or without sedation)

Position Supine position Utilize shoulder roll if hyperextension of the neck is necessary

Prep Shave may be needed prior to prep depending on surgical site Prep is usually omitted on intraoral procedures Prep may be extensive for extraoral procedures, from the face to the nipples

Drape May be minimal or omitted on intraoral procedures Head drape is frequently required for extraoral procedures Square with towels and a thyroid drape for procedures on the external throat

Surgical interventions Laryngoscopy- direct visual examination of the larynx by means of a laryngoscope May be rigid or flexible Most are performed with general anesthesia, but may be done under local

Surgical interventions Excision of salivary gland tumors- removal of glands Require a nerve stimulator Benign is more common than malignant Parotid most common

Surgical interventions Tracheostomy- opening of the trachea and insertion of a cannula through a midline incision below the cricoid cartilage May be permanent or temporary 4% Lidocaine instilled into the trachea to reduce the coughing reflex when the tube is inserted

Surgical interventions Tracheostomy – 2 kinds

Surgical interventions Uvulopalatopharyngoplasty (UPPP)- primarily performed to relive obstructive sleep apnea and snoring Elective tracheostomy may be performed with UPPP, as postoperative edema may cause airway obstruction A tonsillectomy is performed along with the UPPP, if tonsils are present

Surgical interventions Uvulopalatopharyngoplasty (UPPP)

Surgical interventions Partial laryngectomy- removal of a portion of the larynx Performed to remove tumors confined to one vocal cord Cancers here are generally low grade malignancy, and tend to remain localized for long periods of time

Surgical interventions Partial laryngectomy Patient should be prepared for altered voice quality Patient should be informed of the possibility of total laryngectomy should the tumor prove to be too extensive to resect

Surgical interventions Partial laryngectomy Prep and drape as for a thyroidectomy Temporary tracheostomy

Surgical interventions Total laryngectomy- removal of the cartilaginous larynx, the hyoid bone, and the strap muscles attached to the larynx Patient will lose voice, but may learn to speak using an artificial larynx or by using their esophageal voice (swallow air into the esophagus and reintroduce it into the mouth with phonation)

Surgical interventions Total laryngectomy Stump of the trachea is brought out to the skin of the neck to form a permanent stoma

Surgical interventions Radical neck dissection- removal of the tumor, all soft tissue and lymph nodes on the affected side of the neck

Surgical interventions T&A- removal of the tonsils and adenoids

The End Have a GREAT Day!