1. ©2014 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. 1

2. 2 CHAPTER 17 Otorhinolaryngologic Surgery

3. ©2014 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. 3 Objectives After studying this chapter, you will be able to: –Recognize the relevant anatomy of the ear, nose, and upper aerodigestive tract –Summarize the pathology that prompts otorhinolaryngologic surgical intervention and the related terminology –Determine any preoperative otorhinolaryngologic diagnostic procedures/tests

4. ©2014 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. 4 Objectives (cont’d.) –Determine any otorhinolaryngologic preoperative and intraoperative preparation procedures –Indicate the names and uses of otorhinolaryngologic instruments, supplies, and drugs –Indicate the names and uses of special otorhinolaryngologic equipment –Summarize the surgical steps of the otorhinolaryngologic procedures

5. ©2014 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. 5 Objectives (cont’d.) –Interpret the purpose and expected outcomes of the otorhinolaryngologic procedures –Recognize the immediate postoperative care and possible complications of the otorhinolaryngologic procedures –Assess any specific variations related to the preoperative, intraoperative, and postoperative care of the otorhinolaryngologic patient

6. ©2014 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. 6 Introduction to Otorhinolaryngologic Surgery Otorhinolaryngologic surgery –Ranges Simple procedures: myringotomy Complex procedures: laryngectomy –Involves treating diseases and trauma –Includes plastic surgery procedures that often include microsurgery on very small structures

7. ©2014 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. 7 Ear Procedures Many surgical options are available –Correct deformities of the ear –Restore function of the ear

8. ©2014 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. 8 Diagnostic Procedures/Tests for the Ear Tuning fork –Small two-pronged metal device –Emits a clear tone of a fixed pitch when tapped –Used as a diagnostic tool to perform an initial assessment of a patient’s level of hearing –May be used intraoperatively on a patient under local anesthesia to determine improvement

9. ©2014 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. 9 Diagnostic Procedures/Tests for the Ear (cont’d.) Audiometry –More sophisticated method of testing a patient’s hearing Audiometer –Machine capable of emitting a tone at several different pitches and volumes –Patient indicates to the examiner which sounds are heard

10. ©2014 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. 10 Diagnostic Procedures/Tests for the Ear (cont’d.) Otoscope –Handheld, lighted instrument for viewing the external auditory canal –Refer to Figure 17-1 Computed tomography (CT) scan (i.e., computed axial tomography scan) and magnetic resonance imaging (MRI) –Specialized noninvasive methods of viewing the inside of the body

11. ©2014 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. 11 Diagnostic Tools 11

12. ©2014 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. 12 Diagnostic Procedures/Tests for the Ear (cont’d.) Tympanogram –Measures vibrations of the eardrum by placing a probe against the tympanic membrane Electronystagmography (ENG) –Tests the balance mechanism in the inner ear Cool, then warm liquid is introduced into the ear canal Stimulates rapid eye movements

13. ©2014 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. 13 Routine Instruments, Equipment, and Supplies Basic ear procedure instrument tray –Refer to Figure 17-2 Routine supplies –Refer to text

14. ©2014 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. 14 Practical Considerations Operating room and equipment –Prepared prior to the arrival of the patient Microscope –Preparatory steps must be followed for use Ear surgery preparation –Operating table is reversed Refer to Figure 17-3 –Patient position: supine

15. ©2014 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. 15 Practical Considerations (cont’d.) Anesthesia –Usually general anesthesia supplemented with a local anesthetic with epinephrine Draping –May be extensive: head wrap, towels, ear drape, etc. Dressing –May be a very simple (e.g., cotton ball) or quite complex (e.g., mastoid)

16. ©2014 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. 16 Practical Considerations (cont’d.) Repair or replacement of damaged or diseased ossicles or the tympanic membrane –Several options Autografts (from the same person) Allografts (from the same species) Xenografts (from animals) Synthetic grafts

17. ©2014 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. 17 Procedures Include: –Myringotomy http://www.youtube.com/watch?v=alA4PVfkpAc –Tympanoplasty http://www.youtube.com/watch?v=XrdGTW6jUCA –Mastoidectomy http://www.youtube.com/watch?v=VU5Zx_mWKGM –Stapedectomy http://www.youtube.com/watch?v=ioHrRG5Xts8 –Cochlear implant http://www.youtube.com/watch?v=I8eHquhr52s

18. ©2014 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. 18 Nasal Procedures Nose –Facial feature –Serves at the organ for the sense of smell and as the upper portion of the respiratory system Nose and paranasal sinuses –Prone to suffer several types of pathological conditions

19. ©2014 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. 19 Maxillary Sinuses Frontal sinuses Paranasal Sinuses

20. ©2014 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. 20 Nasal Diagnostic Procedures/Tests Diagnostic approaches to nasal and paranasal sinus pathology –Direct vision –Mirror examination –Radiograph

21. ©2014 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. 21 Routine Instruments, Equipment, and Supplies Instrumentation for rhinoplasty –Differs from the instrumentation for internal nasal and sinus surgery Endoscopic sinus surgery –Requires specialized instrumentation and auxiliary equipment Sample nasal instrument set –Refer to Table 17-1

22. ©2014 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. 22 Routine Instruments, Equipment, and Supplies (cont’d.) Routine equipment –Headlamp –Electrosurgery unit (ESU) –Power drill –Insulated ESU with suction attachment –Bipolar unit

23. ©2014 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. 23 Routine Instruments, Equipment, and Supplies (cont’d.) Routine supplies –Basic back table pack –Bar drape and U-drape –Prep and basin set –Gloves –No. 10 and No. 15 knife blades –ESU pencil –Bipolar forceps –Suction system

24. ©2014 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. 24 Practical Considerations Patient positioning –Supine position with the head placed in a donut or foam headrest, or a roll placed under the scapular region Planned local anesthetic –Anesthesia provider will not be in attendance –Use of a small table (prep stand) or second Mayo stand may be requested to hold the supplies for administration

25. ©2014 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. 25 Practical Considerations (cont’d.) Eyewear –Provisions to protect and prevent drying of the patient’s eyes should be made Facial hair –Removal is usually not necessary Draping –May include a turban-style wrap, wound towels, bar sheet, and split sheet or U-drape

26. ©2014 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. 26 Practical Considerations (cont’d.) Following nasal procedures –Nose may be packed with gauze, which may be dry or impregnated with ointment Nose and sinus surgery –Generally done on an outpatient basis Procedures performed through the nose –Not considered sterile procedures

27. ©2014 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. 27 Submucous Resection (SMR) Mucous membrane lining the nasal cavity will be incised –Underlying perichondrium or periosteum lifted –Structures underlying the mucous membrane will be removed to help restore normal breathing –Mucous membrane is then laid back into position and held there with nasal packing material

28. ©2014 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. 28 SMR/Septoplasty Purposes –Straighten a deviated nasal septum –Repair a perforated septum or one damaged by trauma Submucosal approach is used –Cartilaginous or osseous portion of the septum causing nasal obstruction is removed, readjusted, or reinserted

29. ©2014 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. 29 Procedures Include: –SMR/septoplasty –Turbinectomy –Polypectomy –Choanal atresia repair –Functional endoscopic sinus surgery (FESS) –Intranasal antrostomy –Caldwell-Luc

30. ©2014 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. 30 Oral Cavity and Throat Procedures Oral cavity and throat –Consist of several individual and specialized structures that work in harmony to facilitate respiration and ingestion of food Pharynx, larynx, trachea, and esophagus –Can be affected by several conditions Range from minor inflammatory to malignancy as well as mechanical disorders

31. ©2014 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. 31 Diagnostic Procedures/Tests for the Oral Cavity and Throat Include: –Direct and indirect visualization –Laboratory tests Culture and sensitivity Blood count –Radiologic examinations X-rays CT scans MRI

32. ©2014 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. 32 Diagnostic Procedures/Tests for the Oral Cavity and Throat (cont’d.) –Videostroboscopy –Polysomnography –Multiple Sleep Latency Test (MSLT)

33. ©2014 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. 33 Routine Instruments, Equipment, and Supplies Instrumentation used for oral cavity and throat procedures –General surgery major instrument tray with add-ons such as skin hook retractors Exceptions are tonsillectomy and adenoidectomy, and tracheostomy instrument trays: refer to Tables 17-2 and 17-3 –Some health care facilities may have a specialty neck instrument tray

34. ©2014 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. 34 Routine Instruments, Equipment, and Supplies (cont’d.) Operating microscope –Critical part of laryngeal surgery Refer to Figure 17-26 Laser surgery –Becoming common in procedures involving the larynx and oropharynx

35. ©2014 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. 35 Routine Instruments, Equipment, and Supplies (cont’d.) Additional important components –Illumination devices and sitting stools –# No. 12 knife blade –Endoscopes, laryngoscopes, bronchoscopes, and esophagoscopes –Video equipment –Insulated electrosurgical devices –Histological stains and topical anesthetics –Lukens tubes

36. ©2014 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. 36 Practical Considerations Patient positioning –Depends on the patient’s age, type of surgery, and type of anesthetic –Majority will be supine General anesthesia –Usually the anesthesia of choice –May be supplemented with a local or topical anesthetic

37. ©2014 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. 37 Practical Considerations (cont’d.) Supplies –Medicine cups, syringes, and needles –Cotton tip applicators –Anesthetic of choice –Atomizer –Tongue blades –Laryngeal mirror –Small basin of warm water –Gauze sponges

38. ©2014 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. 38 Procedures Include: –Tonsillectomy and adenoidectomy –Parotidectomy –Uvulopalatopharyngoplasty (UPPP) –Laryngectomy –Radical neck dissection with mandibulectomy –Temporomandibular joint arthroscopy –Tracheotomy

39. ©2014 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. 39 Summary This chapter reviewed: –Anatomy of the ear, nose, and upper aerodigestive tract –The pathology that prompts otorhinolaryngologic surgical intervention –Otorhinolaryngologic diagnostic procedures/tests –Otorhinolaryngologic instruments and supplies –Otorhinolaryngologic procedures