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CIS Lesson Plans provide members with ongoing education in the complex and ever-changing area of surgical instrument care and handling. These lessons are designed for CIS technicians, but can be of value to any CRCST technician who works with surgical instrumentation.

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Lesson Plan CIS 217
Otolaryngological Instrumentation
[Reprinted from Communiqué: January/February 2010]

Otolaryngology (pronounced oto-lar-n-gol-o-gy) refers to the diagnosis, evaluation and management of head and neck diseases. The primary focus is on ears, nose and throat, so the discipline is commonly referred to as ENT. Specialties within ENT require numerous instruments for the variety of target organs and applicable surgeries they address. The ears, nose and mouth are natural orifices (openings), and some interventions are conducted through them. This often requires illumination, magnification, and special retracting and holding devices to allow the surgeon to safely reach the target organ. Also, surgical sites are small and access to them may require instruments designed with an angle at their handle or edge.

ENT surgery utilizes both modern surgical techniques (including endoscopic) and traditional surgical techniques. Knowledge about frequently-used ENT instruments will help Certified Instrument Specialist (CIS) technicians understand why these devices require special care.

Historical Background

Some procedures used in present-day otolaryngology, including the tracheotomy to create an opening in the trachea (windpipe), date to 3600 B.C.; However, ENT surgery owes its development to surgeons and researchers who have incorporated technology into techniques, instruments and surgical materials (many of which bear their names).

The medical specialty of otolaryngology expanded in the early 1800s when a metal wire, developed by Dr. Phillip Physick, was worn around a patient’s tonsil until it fell off. During the mid-1800s, Dr. Ernst Krackowiczer developed the laryngoscope to visualize a patient’s larynx (voice box). This led to the development of laryngology, which enabled otolaryngology to provide a more accurate diagnosis of several diseases.

Dr. Solis-Cohen, a surgeon during the American Civil War (1861-1865), is considered the father of laryngology. He developed the total laryngectomy, which is the complete removal of the larynx. Shortly thereafter, Dr. Joseph O’Dwyer performed the first intubation (insertion of a flexible tube into the body) of the larynx. Later development of the bronchoscope and esophgoscope allowed doctors to remove objects in the trachea and develop other treatments for patients.

Restoration of facial expression for patients with facial nerve paralysis began in the 1920s, and Dr. Julius Lempert began fenestration operations (surgical procedures to restore hearing loss from osteosclerosis, or advanced hardening of bone) in the late 1930s. This procedure resolved some hearing problems and was later refined as modern stapedectomy (surgery of the middle ear).

By the 1980s, cochlear implants (insertions of small electronic devices to provide a sense of sound) became commonplace and today physicians are increasingly performing numerous types of ENT surgeries to help their patients.

Primary ENT Specializations

There are four primary ENT specializations:

• Otology – Treatment of ear infection, disease and damage to improve hearing and balance. Some interventions involve conditions deep in the middle and inner ear, and require delicate instruments. Bony and soft tissues may be involved, and instruments may look similar to their orthopedic counterparts (examples: mallets, drills and bone hooks), but on a smaller scale.
  
  In addition to cochlear implants mentioned above, common middle ear surgeries include tympanoplasties (repairs of the eardrum or middle ear bones), stapedectomies (surgical removal of the stapes required by otosclerosis), and mastoidectomies (removal of bone from the mastoid process). Note: the mastoid process is behind the ear canal and contains air cells that drain into the middle ear. Its removal may be necessary because of disease, or if an infected skin cyst is present.
  
  
• Rhinology – Treatment of sinus and nasal disorders, including allergies, to relieve pain, ease breathing and improve nasal function.
  
  Two common interventions are septoplasties (corrections of the nasal septum to enable clear breathing and prevent obstruction) and functional endoscopic sinus surgeries (minimally-invasive procedures for serious cases of inflamed, infected and blocked sinuses).
  
  
• Laryngology – Treatment of diseases of the throat and larynx.
  
  
• Adeno-tonsillectomies (removal of adenoids and/or tonsils) and tracheostomies (surgery on the larynx to create an alternative airway in the throat for patients experiencing difficulty breathing) are two common interventions.
  
  
• Head and neck surgeries – These procedures focus on cysts, glands (including the lymph, salivary, thyroid and parathyroid), and head and neck cancers.

Note: instruments for these surgeries are usually small- and medium- sized basic devices, such as forceps, scissors and dissecting tools.

Common Otolaryngological Instruments

Some ENT instruments are used to access natural orifices. For example, mouth gags keep the mouth wide open, so the surgeon can reach the larynx. They are typically used with a tongue depressor and are self-retained. Ear speculums enable access to external ear, and they may be round or slightly oval, and come in a variety of sizes. Many are ebonized (blackened) to reduce light reflection from the microscope. Nasal speculums have short blades that allow surgeons to view the nasal septum and pathologies of the nostrils, and long blades for use during surgeries. Their openings are controlled with a fixating screw.

Laryngoscopes are usually L-shaped instruments with a handle. The narrow part is inserted into the larynx , and the surgery is performed through it. Long and narrow instruments used for grasping, cutting, or dissecting tissue can be passed down the scope onto the larynx. Their tips must be very small (usually only 1 or 2 mm) since vocal cord structures are also tiny. A long suction tube is also needed for interventions carried out with these instruments.

Other common otolaryngological instruments, while small-scaled and delicate, are similar to those used for other types of surgeries. These include forceps, cutting instruments and other surgical devices.

Forceps grasp tissue and may be straight or angled with a direction: right, left, up, or down. There are several frequently-used types:

• Cup forceps use two opposing small and round- or oval-shaped cups at the end of the shaft to grasp tissue and have a sharp cutting edge with very limited cutting surface. They may be straight or curved up or to the sides with cup dimensions from 0.5 mm to 5-6mm.
  
  
• Alligator forceps have two long and flat metal projections that oppose each other and can grasp tissue. They can be up, down, right, or left depending upon the direction in which the action end is bent. They may also be smooth, serrated or teethed.
  
  
• Crimpers are used to secure a prosthesis (replacement part for the body) by pressing a metal arm to a tissue. The most common type is the McGee Stapes Crimpers.

Cutting instruments for ENT surgery are sharp, and tip protectors are typically required. They are designed to cut soft tissue, cartilage and bones. Common types include:

• Micro-scissors that are straight, curved or angled. These are extremely delicate and must be protected to avoid damage.
  
  
• Sickle knives are spear-shaped and are used to cut small pieces of tissue.
  
  
• Swivel knives use a pulling action that revolves the blade through l80 degrees to cut nasal cartilage tangentially during withdrawal.
  
  
• Other knives include the Rosen and Austin models, and others with different shapes, angles and sizes, according to their intended use.

There are a wide variety of other ENT surgical devices, such as:

• Snares: lumen- (circular or round) shaped metal wires fixed to a device and used to remove tonsils and nasal polyps.
  
  
• Curettes used in adenoidectomy to cut the adenoids.
  
  
• Cutting burrs, diamond- or carbide-coated in varying sizes, used to cut bones. They are attached to a power drill that usually has an attached line to allow fluid to cool the bone while the surgeon drills into it. If burrs are reusable, care is needed to ensure that all bone residue and debris are removed, and a magnifying light is helpful for this purpose.
  
  
• Wire brushes sometimes used to remove bone dust from cutting burrs and other instruments during surgery.
  
  
• Picks with straight or angled tips that can be sharp or blunt and of various lengths. They are used to probe organs, measure canal lengths and perforate tissue, and care is required to protect their delicate tips.
  
  
• Elevators that are sharp or blunt, and available in different angles and sizes. They are used to raise up and retract tissues and separate mucosa (a mucus-secreting membrane) from cartilage. Some elevators are double-sided, and each side may have a different size and shape. Two commonly-used elevators are the periosteal and Freer models.
  
  
• Suction tubes are used to remove blood and other fluids during ENT surgery. Commonly-used types include the Baron, Fraizer, Ferguson, and needle suctions. Suction tubes have a finger cut-off hole that allows surgeons to control suction pressure. This is important to assure that the tissues of delicate ENT organs are not damaged. Some suctions have separate ports for suction and water irrigation.

Interestingly, three different systems are used to express the size (lumen diameter) of suctions. The French system uses larger numbers as tube size increases. In contrast, numbers in the gauge system decrease as tube size increases. Note: needles are usually described in the gauge system. The third system describes tube size in millimeters. Fortunately, conversion tables are available to understand and compare lumen sizes.

Suctions are usually supplied with a metal wire used to remove debris from the lumen during surgery and to check the lumen during reprocessing. Care is required during and after surgery to prevent mucus and blood from drying in the suction cannulae (tubes).

Some Final Thoughts

ENT instruments are delicate and must be carefully reprocessed. Holding devices, racks, tip protectors, and special containers will help provide safe delivery. CIS technicians should disassemble the instruments and use a magnifying device to examine them. Thorough cleaning requires placement on special racks inside washer decontaminators to avoid water pressure damage and to expose their entire surface to the cleaning phase. Manual pre-cleaning is sometimes required for instruments with lumens, those used to cut bone tissue, and for other difficult-to-clean devices.

Assembly of ENT instruments requires specialized knowledge and experience. CIS technicians typically learn about these devices during an advanced stage of their orientation program. Many instruments have surgical tips that can barely be seen and require magnifying devices for inspection and assembly. Fortunately, manufacturer’s catalogs and digital data with multi-dimensional instrument illustrations are useful learning tools.

Take the CIS 217 QUIZ

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