New York-Presbyterian Hospital/Weill Cornell Medical Center April 26-28, 2013 New York-Presbyterian Hospital/Weill Cornell Medical Center ENT Procedures Jason Fowler, MPAS, PA-C Jose C. Mercado, MMS, PA-C

ENT Procedures Workshop ◄ Instruction ● Demonstration ● Practice ► Basic instruction Clear demonstration Hands-on doing! Exchange of ideas Learn by Doing Removal Foreign Body (Nose) Control Anterior Epistaxis Control Posterior Epistaxis Fine Needle Aspiration Peritonsillar Abscess Tracheostomy Care

Introduction There are multiple methods and techniques available to successfully complete all the topics presented in this workshop. Some are based on patient request, available equipment or supervising physician’s preference. The goal of this workshop is to correctly demonstrate the most common methods and give participants time for hands on training.

ENT Procedures Workshop Learning Objectives Discuss indications for and practice removal nasal foreign body. Discuss indications for and practice control anterior epistaxis. Discuss indications for and practice control posterior epistaxis. Discuss indications for and practice fine needle aspiration. Discuss indications for and practice peritonsillar abscess drainage. Discuss indications for tracheostomy and practice tracheostomy care.

Removal Foreign Body (Nose) Purulent unilateral nasal discharge, especially in children Usually lodge on the floor of anterior or middle third Figure. A: Fiberoptic nasal endoscopy shows the mass in the left anterior nasal cavity. B: Coronal CT shows the area of attenuation in the left inferior turbinate. C: Photograph shows the broken mass. D: Following removal of the mass, the passageway is clear. Mercado, JC, Goldberg SG, Recurrent purulent rhinorrhea in an otherwise healthy woman Ear Nose Throat J. 2004 Jun;83(6):381-2

Removal Foreign Body (Nose) Good visualization: headlamp & nasal speculum Alligator forceps should be used to remove cloth, cotton, or paper Other hard FB are more easily grasped using bayonet forceps or Kelly clamps, or they may be rolled out by getting behind it using an ear curette, single skin hook, or right angle ear hook Practice mannequins available to practice removal of nasal foreign bodies technique.

Control Anterior Epistaxis

Control Anterior Epistaxis Control anterior epistaxis in office. Apply direct manual pressure for at least 10 minutes Mercado 2011 © Mercado 2011 ©

Anterior vs Posterior Epistaxis Kiesslebach’s Plexus or Little’s Area is most common site of anterior nosebleeds. Woodruff’s Plexus is most common site for posterior nose bleeds and may represent a lesion. Sphenopalatine artery is generally the source of severe posterior nosebleeds. Posterior more difficult to control will be discussed in Advanced ENT Procedures Workshop.

Etiology of Epistaxis Local Systemic Trauma /Nose picking or blowing / surgery Dry air / Irritants Topical medications (steroids) Foreign body Tumor Systemic Bleeding disorders Hereditary hemorrhagic telangiectasia Drugs (anticoagulants) Hypertension

Direct Manual Pressure NO NO YES A good 10-15 min Mercado 2011 © Mercado 2011 © Mercado 2011 ©

Control Anterior Epistaxis Spray or apply topical anesthetic with decongestant. Reapply direct manual pressure an additional 10 minutes. Mercado 2011 ©

Control Anterior Epistaxis Once bleeding has subsided, identify site of nosebleed. Mercado 2011 ©

Control Anterior Epistaxis Control bleeding with silver nitrate cauterization. (start from outside in) Caution bilateral cauterization as may result in septal perforation. Mercado 2011 ©

Control Anterior Epistaxis Lubricate naris with Vaseline or Neosporin ointment. Let sit for 10-15 minutes to ensure hemostasis is achieved. Keep cotton in nares for at least 1 hour to prevent staining. Avoid sneezing, forceful nose blowing, nose picking, etc. Follow up 2 weeks as re-cauterization may be necessary. Post chemical cauterization stain day 1 Post chemical cauterization stain day 4 Mercado 2011 © Mercado 2011 ©

Anterior Nasal Packing Absorbable gelfoam Vasaline guaze Nasal tampon Anterior packing Mercado 2011 ©

Anterior Nasal Packing Vaseline gauze – is inserted along floor of naris to form a tight seal.

Anterior Nasal Packing Nasal tampon – expands in nasal cavity to form a tight seal. Do not allow packing to moisten until in position. Removal may cause re-bleeding. Mercado 2011 © Mercado 2011 ©

Anterior Nasal Tampon Insert nasal tampon horizontally. Lubricate with Neosporin but DO NOT moisten! Secure ties to cheek. Mercado 2011 © Practice mannequins available to practice anterior nasal packing technique.

Anterior Nasal Packing Easy to insert and remove due to self-lubricating hydrocolloid fabric and ultra-low profile. Packing quickly conforms to nasal anatomy and provides gentle and even compression to areas of epistaxis. Mercado 2011 ©

Anterior Nasal Packing Soak dressing to hydrate Gel Knit hydrocolloid fabric in sterile water for 30 seconds. Insert Rapid Rhino horizontally. Inflate balloon only with air. Tape pilot cuff to side of face. Mercado 2011 © Mercado 2011 ©

How NOT to pack a nose!!!

Control Posterior Epistaxis

Anterior vs Posterior Epistaxis Kiesslebach’s Plexus or Little’s Area is most common site of anterior nosebleeds. Woodruff’s Plexus is most common site for posterior nose bleeds and may represent a lesion. Sphenopalatine artery is generally the source of severe posterior nosebleeds. Posterior tend to be more difficult to control and may suggest an underlying etiology.

Etiology of Epistaxis Local Systemic Trauma (Nose picking or blowing) Dry air / Irritants Topical medications (steroids) Foreign body Tumor / polyp Surgery Systemic Hypertension Coagulopathies Hereditary hemorrhagic telangiectasia Drugs (anticoagulants)

Control Posterior Epistaxis Control Hypertension Identify Coagulopathy –Treat with FFP, transfusions, etc PT, PTT, INR Coumadin toxicity - Vitamin K Posterior Packing Endoscopic Cauterization Arterial Embolization (Interventional Radiology)

Posterior Nasal Packing Topical anesthetic & decongestant Posterior nasal packing Foley catheter Double balloon device

1 2 3 Rapid Rhino® 900 for Posterior Epistaxis Thoroughly soak in sterile water for 30 seconds. Insert Rapid Rhino into the patient’s nostril parallel to the septal floor, or following along the superior aspect of the hard palate, until the blue indicator ring is inside the opening of the nostril. Using a 20 cc syringe, slowly inflate the posterior (green stripe) balloon first with air only inside the patient’s nose.

4 5 6 Rapid Rhino® 900 for Posterior Epistaxis Inflate second balloon with air. Allow the patient to sit for 15-20 minutes prior to discharge. Swelling in the nasal anatomy will reduce and the balloons may need to be inflated more to avoid movement of the device. Don’t forget prophylaxis antibiotics! To remove packing, deflate balloons 24-72 hours later.

Additional Treatments Image on right is a 63-year-old woman with epistaxis refractory to nasal packing. Anteroposterior angiogram shows injection in right distal internal maxillary artery. Medial or septal branches supply septum (straight arrow), and lateral branches supply turbinates (curved arrow). http://www.ajronline.org/content/174/3/84 Endoscopic Cauterization B. Ghorayeb, MD Arterial Embolization Koh E et al. AJR 2000;174:845-851 http://www.ghorayeb.com/EpistaxisPosteriorEndoscopicView.html http://www.ajronline.org/content/174/3/845.full

Control Posterior Epistaxis Practice mannequins available to practice posterior nasal packing technique. Mercado 2011 ©

Fine Needle Aspiration

Site Selection Common sites include thyroid and parotid glands as well as lymph nodes. Mercado 2011 © Mercado 2011 © Mercado 2011 ©

Anesthesia For superficial aspirates, clean technique suffices for cleansing of the skin surface. Local anesthetic may or may not be used. If more than two or three attempts are anticipated, this is recommended. However, be certain not to contaminate the lesion with a large volume of anesthetic. Also, make attempts not to directly interfere with the ability to palpate and localize the lesion. For deep aspirates, sterile technique is required for cleansing of the skin and local anesthetic is usually required.

Fine Needle Aspiration Use a 3, 5, 10 or 20 mL syringe. Use of a “Syringe Pistol” is optional. Needle should be at least 1 ½ inch or appropriate length and be 22 to 25 gauge. Single end label clear glass slides (for preparation of direct smears). Fixative to preserve fixed slides (either Cytology spray fixative, Saccomanno fixative or 95% ethyl alcohol in coplin jar). Mercado 2011 ©

Fine Needle Aspiration Palpate and identify mass or lesion. Clean topically with alcohol. Stabilize the mass with non-dominant hand. Insert needle through the skin with a quick motion. Mercado 2011 © Mercado 2011 ©

Fine Needle Aspiration Advance through the subcutaneous tissue into the mass. Aim needle toward the center of small masses but toward the periphery of larger masses as the center may be necrotic. A noticeable difference in the consistency of the tissue should be noted when the needle penetrates the mass. With the needle in the mass, the needle tip should be moved in short motions initially to loosen cells within the mass. Pull back on plunger to create negative pressure. Fowler 2011 ©

Fine Needle Aspiration Without releasing pressure, withdraw the needle within the target slightly then reinsert at a slightly different angle. Repeat maneuver several times before complete withdrawal. May also perform a corkscrew action before withdrawal. If blood or material appears in the hub of the needle, the aspiration should be stopped. Release negative pressure before withdrawing the needle, negative pressure must be released to prevent suction of the material into the barrel of the syringe when the needle exits the skin. Fowler 2011 ©

Transfer specimen from needle hub to slides. Preparing Slides Transfer specimen from needle hub to slides. Gently and evenly spread specimen between two slides before fixing. Allow to air dry before closing slide holder. Mercado 2011 © Mercado 2011 ©

Fine Needle Aspiration Aspiration techniques vary widely based on personal preference, and specific clinical circumstances. Goal is to collect adequate cellular material for cytologic evaluation. Practice mannequins available to palpate and practice technique.

Peritonsillar Abscess

Peritonsillar Abscess History Severe Odynophagia Dysphagia Physical Fever Unilateral edema Hot Potato Voice Elevated white count (CBC) CT Scan with contrast Fowler 2011 © Patients with PTA may not have fever but will have an elevated white count. CT Scan with contrast will confirm abscess formation versus cellulitis, phlegmnon or severe tonsillitis.

Peritonsillar Abscess Strong clinical suspicion without obvious physical findings. Above patient had previously presented to emergency department with severe sore throat and was sent home on amoxicillin. She returned 3 days later with persistence of symptoms. She had a slightly elevated white count and CT Scan confirmed a 1.5cm x 2 cm right peritonsillar abscess. Mercado 2011 © Mercado 2011 ©

Equipment needed Hurricaine spray Lidocaine w/ epi Tongue Blade Mercado 2011 © Equipment needed Hurricaine spray Lidocaine w/ epi Tongue Blade Scalpel Headlight Suction setup Long tonsil clamp Culturette

Peritonsillar Abscess Management options Needle aspiration Incision and Drainage Quinsy tonsillectomy Choice will depend on site and location of abscess. Smaller, deep abscess are sometimes easier to reach with large bore needle. Both have similar success rates (Needle Aspiration 90-95% vs I and D 90-100%)

Peritonsillar Abscess Aim medial. Critical area is lateral pharyngeal space which connects to all other spces.

Needle Aspiration Mercado 2011 © Mercado 2011 ©

Incision and Drainage Incision & Drainage with #15 blade Blunt Disection with curved hemostat Have ice water and yankauer suction ready…. Mercado 2011 © Mercado 2011 ©

Peritonsillar Abscess Discharge instruction : Penicillin based antibiotics Oral prednisone In-office follow up, possible tonsillectomy Mercado 2011 © Mercado 2011 © Practice mannequins available to simulate PTA and practice needle aspiration technique.

Tracheostomy Care

Clinical Consensus Statement: Tracheostomy Care Clinical consensus statement (CCS) Aims to improve care for pediatric and adult patient with a tracheostomy tube. Approaches to tracheostomy care are currently inconsistent among clinicians and between different institutions. The goal is to reduce variations in practice when managing patient with a tracheostomy to minimize complications. Variations in care and management of patient with a tracheostomy exist between hospitals, inpatient and outpatient facilities, and in the emergency room. Presently, the current literature does not support the development of clinical practice guidelines but favors a consensus of expertise.

Selection of Tracheostomy Tracheostomy tubes come in different sizes and different materials. Two types of tracheostomy tubes commonly used are Polyvinyl chloride tracheostomy tubes (Shiley) and Silicone (Bivona). Shiley tubes are slightly flexible and Bivona are the most flexible. Both Shiley and Bivona tubes come standard with a universal adapter for ventilation. In double cannula tubes, the inner cannula is inserted and locked in place after the obturator is removed. The inner cannula can be removed briefly for cleaning. The outer tube is secured to the paitent. Single cannula tubes are often used in children and do not have an inner cannula. The Tracheostomy Care portion of the workshop will ONLY focus on dealing with complications associated with ; Obstruction Decannulation (Accidental & Intentional) Bleeding Leaks Changing tracheostomy

Selection of Tracheostomy Fenestrated tracheostomy tubes facilitate speech by allowing better translaryngeal air flow. Some clinicians believe that fenestrated tubes also aid in the clearance of secretions. Other clinicians feel that these tubes promote the development of granulation tissue along the tracheal wall at the level of the fenestrations. Since there is little scientific data to support either opinion, it is up to surgeon’s preference. Cuffed tubes have a balloon at the distal end of the tube and allow for mechanical ventilation. Uncuffed tubes are generally preferred in children. Except when requiring ventilation with high pressures, requiring ventilation only at night, or with chronic translaryngeal aspiration.

Obstruction Position the patient’s head with a roll under the shoulders. Ensure that the outer opening of the tube is clear. Check that the tube is in the proper location. It should be against the neck, and the obturator should not be in place. If the patient has a fenestrated tube, remove the decannulation plug. Give oxygen (over the tracheostomy tube), then looses secretions by placing up to 1 to 2 ml of normal saline into the tube. Suction the tube with a suction catheter set to 100 mmHg or less. Insert the suction catheter approximately 2 to 3 inches into the tube. If the patient begins to cough, the catheter is through the tube and into the trachea, and the depth of insertion is correct. Do not use suction while inserting the catheter, and never force the catheter. Cover the suction port (hole) and suction for 3 to 5 seconds, while slowly removing the catheter. Never suction for longer than 10 seconds. Always monitor the patient’s heart rate and color during this procedure. Stop suctioning immediately if the heart rate begins to drop or the patient becomes blue. If the obstruction is removed, and the patient can breathe on his/her own, do not suction further. If additional suctioning is needed, apply oxygen (by blow-by or direct ventilation) and repeat steps Mercado 2011 © Mercado 2011 © Mercado 2011 ©

Accidental Decanulation Early accidental decanulation. Nasal speculum Obturator Risk of false tract/fistula Mercado 2011 ©

Leaks A low-pressure, high volume cuff is preferred to avoid unnecessary injury to the tracheal mucosa such as tracheal malacia. Check cuff pressure first. Consider changing to a longer tracheostomy tube. Monitor cuff pressure on a regular basis. Shiley® Tube Size Leak Test Volume 10 20cc 8 17cc 6 14cc 4 11cc

Bleeding Local bleeding Controlled with Granulation tissue Superficial bleeding from mucosa Small vessels Controlled with Pressure dressing Gelfoam Chemical cauterization

Bleeding But for anything more than oozing. Must rule out tracheo-innominate artery fistula (TIAF). Caused include; Low tracheostomy High innominate artery Cuff overinflation Infection

Bleeding TIAF may cause massive hemorrhage in 0.7% of tracheotomies. 2/3 occur in first 3 weeks after tracheostomy Long-term intubation and ventilation. Cuffed or uncuffed tube.

Changing Tracheostomy In the absence of aspiration, tracheostomy tube cuffs should be deflated when the patient no longer requires mechanical ventilation. A patient initial tracheostomy tube should normally be replaced within 10-14 days. The Panel agreed an experienced physician should ideally be present for the first tube change, although there are was recognition that in some facilities, this may not be feasible and thus performed by an experienced advanced practice provider (APP) with immediate physician backup available. In an emergency, a dislodged, mature tracheostomy tube should be replaced with the same size or a size smaller tracheostomy tube. If those are not available for could not be inserted, then an appropriately sized endotracheal tube should be placed through the wound into the trachea. In a patient in whom a tube could not be replaced, resulting in hypoxia or concern for eventual loss of airway, they should undergo oral tracheal intubation or immediate surgical revision tracheostomy.

Downsizing, capping and decannulation When the adult patient is in the hospital and; Does not require mechanical ventilation Indication for tracheotomy has resolved Patient tolerates breathing through the tracheotomy tube with the cuff deflated. Breathing with a cuffless #6 Shiley tube is checked (smaller patients, a cuffless #4 Shiley tube is placed) Patient tolerates capped tracheostomy with a red button. If the patient is stable (normal oxygen and CO2) for 24 – 48 hours with the trach plugged, the tube will be removed by a qualified physician or mid-level provider, and the stoma will be allowed to close. Downsizing, capping and decannulation 62

Downsizing, capping and decannulation

Decannulation When the patient succeeds at decannulation sequence, 1. Wound margins should heal by secondary intention, with initial wound co-apting in 5 to 7 days (unless wound was created with a fenestration technique) 2. New epithelial cells grow across wound in 7 to 10 days. No leak of air from the wound at this time. 3. If wound does not heal, then wound may be closed surgically, by separating trachea from the skin, and closing the wounds in layers. 4. If scar appearance is not acceptable, wound may be closed in a transverse incision across the lower neck with a plastic closure. 64

Decannulation Assess the patient for associated anomalies of the nervous, respiratory, cardiovascular and gastro-intestinal systems. Re-examine the airway for associated problems: nasal obstruction, adenoid hypertrophy, tonsil hypertrophy, macroglossia, glossoptosis, micrognathia, lingual tonsil hypertrophy, laryngomalacia, glottic web, sub-glottic stenosis, tracheal stenosis or granulation Mercado 2011 © 65

Late Complications Bleeding Tracheomalacia Stenosis Tracheoesophageal fistula Tracheocutaneous fistula Granulation Leaks Mercado 2011 ©

Tracheotomy- Conclusion Identify source of leaking and bleeding. If unable to safely change tracheostomy at bedside consider revision tracheostomy in OR. Care of the tracheostomy tube and the wound require planning and communication. Do only as much as you have been trained to, feel comfortable doing and is within your scope of practice. Mercado 2011 © Practice mannequins available to practice tracheostomy care technique. 67

Clinical Consensus Statement Tracheostomy tube should be changed using a clean technique. A sterile technique is not necessary and does not lead to a reduction in impaction. Plastic tracheostomy tube should be used among pediatric and adult patients for initial tube placement. Tracheostomy tube ties it should be used unless the patient recently underwent local or free flap reconstructive surgery or other major neck surgery. No patient should be discharged with tracheostomy tube sutured in place. Any suture securing a tracheostomy should be removed during first tube change. Stoma and tracheostomy tube should be suctioned when there is evidence of visual or audible secretions in the airway, suspected airway obstruction, and whether tube is changed or deflated.

Aaron’s Tracheostomy Page Links Aaron’s Tracheostomy Page http://www.tracheostomy.com/

ENT Procedures Practice Stations Control A/P Epistaxis Removal FB Station 4 PTA Chair SMR * Station 2 Control A/P Epistaxis Removal FB Station 5 FNA Station 3 Trach Care Station 6 FNA *suction