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.
For Online Grading (www.iahcsmm.org):
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Each lesson plan graded online with a passing score of 70% or higher is worth two points (contact hour). You can use these points toward either your re-certification of CRCST (12 points) or CIS (6 points).
Mailed submissions to IAHCSMM will not be graded and will not be granted a point value (paper/pencil grading of the CIS Lesson Plans is not available through IAHCSMM or Purdue University; IAHCSMM accepts only online subscriptions of the CIS Lesson Plans)
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.
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.
There are four primary ENT specializations:
Note: instruments for these surgeries are usually small- and medium- sized basic devices, such as forceps, scissors and dissecting tools.
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:
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:
There are a wide variety of other ENT surgical devices, such as:
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).
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.
Yaffa Raz, RN, BA
Central Service Sterile Department Manager
Lady Davis Carmel Medical Center
Carla McDermott, RN, ACE
Morton Plant Mease Healthcare
Jack D. Ninemeier, Ph.D.
Michigan State University
East Lansing, MI