ENT Surgery

Objectives review A/P of the ear identify otological pathological conditions distinguish between types of otologic procedures describe basic surgical interventions myringotomy describe intermediate surgical interventions tympanoplasty I describe advanced surgical interventions tympanoplasty II

mastoidectomy review A/P of the nose identify nasal pathological conditions differentiate between types of nasal procedures describe intermediate surgical interventions Caldwell-Luc describe basic surgical interventions septoplasty sinuscopy

review A/P of the upper aerodigestive tract identify oral pathological conditions distinguish between types of oral procedures describe basic surgical interventions tonsillectomy/adenoidectomy laryngoscope microlaryngoscopy bronchoscope describe intermediate surgical interventions UPPP

describe advanced surgical interventions laryngectomy radical neck dissections review A&P of oral cavity, face, cranium distinguish between oral pathological conditions differentiate between oral procedures describe basic surgical interventions LeFort I describe intermediate surgical interventions LeFort II

describe advanced surgical interventions LeFort III describe intermediate surgical interventions odontectomy ORIF maxillary/mandibular fractures describe basic surgical interventions temporomandibular joint arthroplasty distinguish between face and skull pathological conditions

differentiate between face and skull procedures describe intermediate surgical interventions orbital fracture reduction/stabilization describe advanced surgical interventions craniofacial reconstruction

inner ear outer ear middle ear tympanic membrane pinna/ auricle external auditory canal cerumen middle ear

malleus incus stapes auditory ossicles

inner ear otic capsule bony labyrinth membranous labyrinth semicircular canals cochlea vestibule oval window bony labyrinth membranous labyrinth

vestibule separates cochlea/ semicircular canals contains two sacs utriculus sacculus stationary equilibrium

semicircular canals contain cristae sensitive hair cells equilibrium moving

vestibular branch of vestibulocochlear (VIII) carries impulse cerebral cortex vestibular

cochlea organ of corti organs of hearing hair cells

cochlear nerve of vestibulocochlear nerve carries impulse temporal lobe

physiology of hearing sound enters auditory canal tympanic membrane vibrates air conduction malleus vibrates incus vibrates staples vibrates bone conduction

oval/round window vestibule cochlea fluid conduction neural conduction

ear procedures remove all glove powder prevent granuloma adhesions

pathology of the ear deafness congenital deafness present at birth neonatal deafness time of birth

conduction-type prevention sound waves infection otosclerosis occlusion of external canal sensorineural damage to cochlea damage to 8th CN damage to CNS

functional deafness psychogenic nature no problem identified

cochlear implants prosthetic replacement for cochlea contraindicated until 2 years old

internal receiver postauricular region internal processor temporal bone active electrode through round window cochlea

outer ear pathology obstruction of canal excessive cerumen foreign body bony growths exostoses soft tissue growths polyps

otitis externa infection outer ear swimmer’s ear

middle ear pathology otitis media infection middle ear myringotomy

myringotomy pathophysiology recurrent otitis media diagnostic intervention otoscope

surgical intervention special considerations microscope in room check size of lens reverse OR bed surgeon head of bed pediatric patient preferred anesthesia general mask

position supine donut/black pillow prepping/draping hair cover usually no prep or drape incision circumferential posterior inferior

supplies PE tubes mayo stand cover suction tubing equipment microscope sitting stool instruments myringotomy tray

procedural steps insert speculum Farrior (Boucheron) excise cerumen Buck’s ear curette incision in tympanic membrane Sexton knife suction Frazier

load PE tube Hartman alligator forceps insert antibiotic/anti-inflammatory packed with cotton complications recurrent infection

tympanic membrane perforation external trauma excess pressure treatment myringoplasty tympanoplasty

myringoplasty similar to myringotomy prepped avoid pooling in ear ototoxic perforated TM edges everted scratched

patch over defect gelfoam, steri-strip, fat graft posterior portion ear lobe canal packed Glasscock dressing plastic bowl gauze sponges Velcro straps

tympanoplasty tympanoplasty I perforated TM tympanoplasty II malleus damaged tympanoplasty III malleus and incus damaged stapes intact and mobile

tympanoplasty IV ossicle chain missing stapes footplate mobile tympanoplasty V ossicular chain intact stapes fixed

tympanoplasty I pathophysiology perforation of tympanic membrane cholesteatoma mass of skin accumulation of keratin hearing loss diagnostic intervention otoscope/audiometry

surgical intervention special considerations reverse OR bed for surgeon position supine donut/black pillow preferred incision transaural or postauricular

supplies basic pack head/neck drapes microscope drape hemostatic agents bone wax gelfoam

equipment microscope sitting stools ear drill instruments ear instrument set

procedural steps makes incision #15 blade excises temporalis fascia autograft graft flattened and shaped fascia press left in open position graft to dry

perforated tissue excised Bellucci scissors lancet knife may need to enlarge canal ear drill drip NS prevent heat

fascia graft trimmed #15 blade fascia press inserts graft alligator forceps fine Rosen needle

ear packed gelfoam incision closed mastoid dressing complex procedures fluffs Kling or Kerlix around head

complications hemorrhage/infection failure to restore hearing

tympanoplasty II pathophysiology perforated TM damaged malleus surgical intervention special considerations ossicular implants available

procedural overview diseased tissue and ossicles removed ossicular reconstruction graft anastomosed to remaining ossicles

alternative treatments cholesteatoma mastoidectomy neoplasms nonfunctioning eustacian tubes

mastoidectomy surgical intervention special considerations microscope OR bed reversed

procedural overview simple mastoidectomy removal of mastoid air cells postauricular incision Janssen retractor burr to mastoid sinus Stryker may want drain

modified radical mastoidectomy removal of posterior/superior walls external auditory canal eradication of mastoid air cells radical mastoidectomy removal of mastoid air cells eardrum malleus incus

otosclerosis bony overgrowth of stapes locks stapes in place treatment stapedectomy

stapedectomy Shea universal speculum holder removal of fixed stapes reconstruction of ossicular chain soft tissue graft over oval window stapedotomy incision into fixed footplate

inner ear pathology Meniere’s syndrome vertigo, tinnuitis, progressive deafness endolymphatic shunt shunting excess fluid labyrinthectomy

removal of acoustic neuroma benign tumor of 8th cranial nerve covered in neurosurgery

bridge dorsum ala apex external nose base

nasal bone cartilage

conchae turbinate baffles hard palate soft palate nares uvula internal nose

frontal ethmoid sphenoid maxillary paranasal sinus

smell olfaction chemoreceptors nasal cavity olfactory nerve temporal lobe

pathophysiology rhinitis/sinusitis polyps allergic rhinitis treat with steroids polypectomy scope sinuses

sinus endoscopy direct visualization sinuses pathophysiology diagnosis treat sinusitis remove polyps diagnostic intervention x-rays

surgical intervention anesthesia general position supine donut/black pillow

prepping face cover eyes cotton balls to ears draping turban/towels wrapped around head fan sheet down sheet

supplies minor pack drapes Fred equipment light source instruments rigid scope

procedural steps inject local 1% with epinephrine nasal speculum bayonet forceps packed with cottonoids decongestant insert scope provide suction antrum cannula

remove diseased tissue Wilde forceps biopsy forceps microdebrider achieve hemostasis apply mustache dressing decongestant

maxillary anstrostomy inflammatory disease polyps maxillary sinus ethmoidectomy nose frontal sinus change to 30 or 70° sphenoidectomy

radical antrostomy Caldwell-Luc pathophysiology intractable infection antrostomy huge polyps disease of antrum osteonecrosis neoplasm

surgical intervention room setup routine position supine head of bed elevated black pillow/donut

supplies minor pack head/neck drapes #15 knife frazier suction equipment drill instruments nasal/sinus set Caldwell-Luc retractor

procedural steps retracts lip raytec incision into gums above canine/2nd molar gingivo-buccal sulcus #15 blade

retract mucous membrane army-navy periosteum elevated infraorbital nerve identified freer elevator perforation of bone drill osteotome/mallet Kerrison rongeur

sinus evacuated frazier suction polyps removed Hartman nasal forceps Wilde forceps Takahashi forceps hemostasis achieved wound closed

hypertrophied turbinates chronic rhinitis nasal obstruction SMR/turbinectomy all or some turbinate removed

turbinectomy #15 blade anterior border inferior turbinate turbinate removed Wilde forceps Coblator

deviated nasal septum due to aging trauma leads to difficulty breathing sinusitis treatment septoplasty

diagnostic intervention visual examination surgical intervention special considerations advise patient breathe through nose postoperative

anesthesia local general preferred position supine donut/black pillow

prepping surgeon shaves interior nose #15 blade bayonet forceps local available cocaine solution cover eyes with saline prep face

draping turban headwrap towels folded surgeon’s preference fan sheet down portion

supplies minor pack #15 blades cautery extension packing materials splint materials

equipment routine headlight instruments nasal/sinus set

procedural steps Cottle/Killian nasal speculum incision into mucous membrane #15 blade interior nose incision into cartlidge Cottle/Joseph septal knife septum elevated freer elevator

frazier suction available deviated structures excised chisel/mallet Fomon nasal rasp bayonet forceps Knight/Joseph nasal scissors

achieve hemostasis suture dressing applied packing splint suction pharynx

septal perforation causes carcinoma, chronic infection, intractible picking, chemical exposure, substance abuse treatment septoplasty

rhinoplasty cosmetic correct nasal tip elevation hump removal smaller straighter Ash forcep narrower

hump removed with rasp or chisel reconstruction cartilage or bone graft saved during septoplasty straighten or narrowing lateral osteotomies

epistaxis nose bleed treatment pressure packing cauterization artery ligation

anosmia absense of smell hyperosmia sensitivity to odor parosmia disorder of smell

oral cavity

pharyngeal tonsils nasopharynx eustacian tube palantine tonsils oropharynx laryngopharynx

epiglottis hyoid bone vocal cord larynx

thyroid cartilage cricoid cartilage trachea

pathophysiology pharyngitis strep epiglottitis Hemophilus influenzae may lead to tracheotomy

choanal atresia congenital occlusion nasopharyngeal area inhibits respiration

tonsillitis palantine tonsils tonsillectomy hypertrophy peritonsillar abscess adenoiditis adenoidectomy

tonsillectomy diagnostic intervention visual examination repeated occurrences surgical intervention special considerations age specific factors may turn OR bed

anesthesia general position supine, neck hyperextend donut/black pillow prepping none draping head drape down sheet

supplies back table cover tonsil sponges #12 knife blade suction/cautery ¾ sheet equipment headlight instruments T&A set

procedural steps self-retaining mouth gag Davis/Jennings/ McIvor/Denhart no touch mayo stand tongue depressed Wieder/Andrews

grasp tonsil Allis (tonsil) mucosa of anterior pillar incised #12 blade Hurd dissector tonsil excised snare Eve/Tyding

removed Coblater laser Fisher knife cautery protect lip burning wet Raytec insulated

pressure applied tonsil sponge hemostasis achieved suction/cautery suction available anesthesiologist transportation positioned on side for

complications hemorrhage extubation up to 10 days infection

adenoidectomy excision of adenoids eradicate infection hypertrophy primary reasons

adenoidectomy retract the palate red rubber catheter remove adenoids Coblator Barnhill adenoid curette suction cautery inspects area laryngeal mirror

sleep apnea brief interruptions respiration treatment medical CPAP surgical UPPP

uvulopalatopharyngoplasty removal of fauces tissue, tonsils, uvula, and portion of soft palate diagnostic intervention sleep lab

surgical intervention special considerations be prepared tracheotomy may want laser position supine, neck hyperextend black pillow/donut

supplies similar to T&A laser components tracheotomy supplies equipment laser instruments T&A set

procedural steps self-retaining mouth gag tonsillectomy performed retracts uvula posteriorly Allis excises soft palate/uvula cautery soft palate sutured

complications hemorrhage infection airway obstruction swelling tracheostomy set available

laryngitis laryngoscope pathophysiology diagnosis foreign bodies papilloma vocal cords polyps leukoplakia pre-cancerous

indirect laryngoscope laryngeal mirror direct laryngoscope laryngoscope suspension microlaryngoscope self-retaining

surgical intervention special considerations microscope available position supine, neck hyperextended black pillow/donut head at end of bed OR bed turned 90°

supplies back table cover lukens tube K-Y jelly equipment light source sitting stool microscope

instruments laryngoscope laryngeal suction tips fiberotic light cord tooth protector laryngeal mirror larygneal biopsy forceps

procedural steps scope inserted provide suction lesions identified biopsy forceps hemostasis acheived

complications hemorrhage infection voice quality affected

neck anatomy organized into triangles sternocleidomastoid preserve vagus nerve phrenic nerve recurrent laryngeal nerve

airway management longterm tracheotomy incision into trachea tracheostomy opening into trachea

surgical intervention special considerations airway priority emergency prepared position supine patients hospital bed

supplies minor pack tracheostomy tube equipment routine instrumentation trach tray

procedural steps incision cricoid cartilage #15 blade separate strap muscles elevate the trachea tracheal hook

incision into trachea #15 blade anesthesia withdraws ET tube tracheostomy tube inserted obturator inside tube inflated obturator removed internal cannula inserted

connect to ventilator may or may not suture tracheotomy ties

submandibular gland excision chronic infection neoplasm parotidectomy lymph node

thyroplasty medialize paralyzed vocal cord cancer of the tongue base glossectomy cancer of the oropharynx

laryngeal neoplasms larygnoscope w/biopsy benign malignant laryngectomy radical neck dissection

laryngectomy hemilaryngectomy one true vocal cord, one false vocal cord, arytenoid, half thyroid cartilage supraglottic laryngectomy epiglottis, false vocal cords, hyoid bone total laryngectomy entire larynx, hyoid, cricoid cartilage, upper tracheal rings

surgical intervention special considerations preoperative teaching loss of voice trachea postoperatively procedural overview tracheotomy midline incision specified tissue dissected tracheal stoma formed

neck dissection prevent further metastasis type of dissection extent of node involvement selective neck dissection 1 or more cervical node chains preserved nonlymphatic structures

modified radical all cervical lymph nodes 1 or more nonlymphatic structures preserved radical surrounding structures spinal accessory nerve internal jugular vein sternocleidomastoid

pectoralis myocutaneous deltopectoral flap cover soft tissue defects

Oral/Maxillofacial Surgery

anatomy of the midface bones anatomy of the mandible

pathology of oral cavity dental caries tooth extraction tooth restoration implantation prosthetic tooth gingivitis cancer or cysts of mouth

tooth extraction surgical intervention special considerations not sterile clean procedure bed positioned to allow access cream or ointment to lips

position supine, head tilted back donut, black pillow instruments dental set

supplies minor pack #15 blades throat pack dental rolls equipment dental drill irrigation/suction system

procedural steps bite block inserted prevent injury facilitate visualization maintain open position throat pack placed probe to determine gingivitis

gingiva removed surface of tooth periosteal elevator tooth removed alveolar surface extraction forceps

alveolar socket inspected remaining tooth drilled irrigation hemostasis achieved pharynx suctioned throat pack removed

complications hemorrhage/infection malocclusion

dental implants pathophysiology replace lost dentition endosteal implants subperiosteal implants transosteal implants

bilateral fractures maxilla Le Fort I closed reduction w/arch bars panfacial fractures Le Fort II open reduction w/internal wire fixation

Le Fort III craniofacial dysfunction w/nasal zygomatic fractures open reduction w/internal wire fixation intermaxillary fixation w/arch bars

LeFort I surgical intervention special considerations preoperatively trachosteomy arch bars dental impressions x-rays in room anesthesia general

position supine donut/black pillow prepping may shave entire face prepped draping turban U-drape down drape

supplies equipment same as internal fixation instruments maxillofacial instrument set internal fixation system

procedural steps gingivobuccal incision expose maxilla fracture line exposed freer periosteal elevator fracture reduced elevator manual

drill holes for wire fixation twisted clockwise cut ends imbedded x-ray

maxillary/mandibular fractures application of arch bars maxillomandibular fixation wire fixation plate and screw fixation

arch bars irrigate the mouth shapes arch bar upper teeth/gums retracts cheek sweetheart wires bar in place 24 or 26 gauge wire Rubio needle holder

wires threaded between teeth twisted cut applied to lower twisted together rosebud

plate and screw fixation surgical intervention special considerations may need x-rays position supine donut/black pillow

supplies basic pack #15 blades head/neck drapes irrigation fluid throat pack

equipment drill and drill bits screws monocortical outer layer bicortical entire bone

instruments internal fixation system maxillofacial instrumentation

procedural steps incision anterior angle of mandible periosteum stripped from bone periosteal elevator freer elevator bone edges manipulated together plate selected

drill guide hole drilled depth assessed tap screw placed in hole plate attached to bone x-ray

postoperative complications numbness chin injury mental nerve

midface fracture repair frontal fracture repair orbital fracture repair BSS irrigation reduction of zygomatic fractures maxilla fracture repairs

persistent pain dysfunction of jaws temporomandibular joint disease

temporomandibular joint procedures arthroscopy meniscal repair joint replacement

craniofacial reconstruction craniosyntosis anterior cranial expansion posterior cranial expansion