Instruments used in Otolaryngology

This presentation discusses various instruments that are used in otolaryngological surgeries

1. Instruments in Otolaryngology Prof. Balasubramanian Thiagarajan (drtbalu)

2. Types of instruments Instruments used in Outpatient department Instruments used in the Operation theatre Instruments used both in OPD and Operation theatre This classification is a must in order to decide the sterilization protocol that needs to be followed drtbalu's otolaryngology online

3. Spaulding classification Critical – Objects which enter normally sterile tissue or the vascular system and needs to be sterilized Semi-critical - Objects that contact mucous membranes or non-intact skin and require high level of disinfection, which kills all but high levels of bacterial spores Non-critical - Objects that contact intact skin but not mucous membranes and require low level disinfection drtbalu's otolaryngology online

4. Sterilizing semi critical instruments Instruments that comes into contact with mucous membranes and non intact skin comes under this category. Examples: endoscopes, anesthesia equipment, instruments used in OPD. These instruments should be sterilized or immersed in high level disinfectant Goal - To free the instrument from all micro organims except low numbers of bacterial spores drtbalu's otolaryngology online

5. High level disinfectants Germicide Concentration Glutaraldehyde 2% Ortho- phthaladehyde 0.55% Hydrogen peroxide 7.5% Hypochlorite 650-675 ppm Accelerated hydrogen peroxide 2% Peracetic acid 0.2% Glutaraldehyde and isopropanol 3.4% Contact time 8-45 minutes drtbalu's otolaryngology online

6. Noncritical instrument sterilization Disinfected using low level disinfectants Role is to kill vegetative bacteria / fungus / viruses Instruments that come into contact with intact skin belong to this category i.e. nasal speculum, BP apparatus aural speculum etc drtbalu's otolaryngology online

7. Low level disinfectants Disinfectant Concentration Ethyl / isopropyl alcohol 70-90% Chlorine (bleach) 100 ppm Phenol UD Quaternary ammonium compound UD Improved hydrogen peroxide 0.5-1.4% Exposure time about 1 minute drtbalu's otolaryngology online

8. Thudichum’s nasal speculum John Louis William Thudichum drtbalu's otolaryngology online

9. Thudichum’s speculum uses This instrument is routinely used in OPD to examine the nasal cavity. It has two flanges that can be inserted into the nostril during anterior rhinoscopy. The flanges widen to open up the nasal cavity, thereby offering a better view of intranasal structures. In anterior rhinoscopy Foreign body removal from the nose Peroperative nasal packing In septal surgeries to make incision drtbalu's otolaryngology online

10. Method of holding Thudichum’s speculum drtbalu's otolaryngology online

11. Head mirror Concave mirror Focal length 10 inches Has a plastic headband with a lever and two ball and socket joints Distance between doctor & patient – 8 inches Mirror is fixed over right eye and should touch the nose Right eye sees through the centre hole & left eye sees outside the mirror drtbalu's otolaryngology online

12. Bull’s lamp Semi mobile illumination 100 watts milk white bulb is the source of illumination Should be placed 6 inches above and behind the left shoulder of the patient at the level of the left ear drtbalu's otolaryngology online

13. Aural syringe Capacity 120 ml (4 fluid ounces) Reiner Alexander type has a shield which blocks fluid from spilling over the surgeon’s lap Temperature of saline used should ideally be body temperature (neither too hot nor too cold) Reiner Alexander Simpsons drtbalu's otolaryngology online

14. syringing procedure The patient should be comfortably seated in front of the examiner. The procedure should be explained in detail to the patient. If the patient is a child, then its confidence should be won by allowing the child to handle the syringe prior to use The patient should be properly draped with waterproof sheets to avoid dress from becoming wet. Temperature of water used for syringing should be of body temperature. It should neither be too hot nor too cold. Temperatures lesser / greater than that of body temperature would stimulate the labyrinth causing giddiness. While syringing the nozzle of the syringe must be directed towards the roof of the external auditory canal and should not be directed towards the posterior canal wall because it could stimulate vagus nerve which innervates the posterior canal wall. Stimulation of vagus nerve could cause giddiness and fainting of the patient. Nozzle should be secured Instruct the patient (if able) to hold the kidney tray under the ear. This will enable the patient to take his / her attention away from the procedure. If the patient is not able to do it then assistance can be sought for. drtbalu's otolaryngology online

15. Aural syringing contraindications Ear drum perforation Recent history of middle ear infection Presence of otitis externa Presence of hygroscopic FB drtbalu's otolaryngology online

16. Siegel's speculum Used to perform pneumatic otoscopy Mobility of ear drum can be tested Provides two and half times magnification of the ear drum drtbalu's otolaryngology online

17. Siegel’s speculum parts Bulb - Made from rubber with a one-way valve which will enable it to pump out air. It is connected by a rubber tube to a speculum adapter. The speculum adapter is provided with a slanting lens which is convex in nature. This lens provides 2 1/2 times magnification of the image. Three aural specula are provided. Their sizes being 4, 5, and 6 mm. These aural specula fits snugly into the speculum adapter. Eye piece which is placed obliquely to make it parallel to the ear drum. The lens is convex and creates a magnification of two and half times. drtbalu's otolaryngology online

18. Siegel’s speculum uses Seigalisation: This test is done to test the mobility of the ear drum. The speculum should be snuggly fitting for this test to be performed. The speculum should be introduced in such a manner that the eye piece is oriented towards the antero inferior slant of the ear drum. Pressure at the external canal is applied by pressing the bulb. The ear drum could be seen moving inwards. On releasing the pressure in the bulb negative pressure is created pulling the ear drum towards the speculum. Normally this to and fro movement of the ear drum can be observed during this procedure. . Fistula test: On performing seigalisation test if the patient is having fistula of the lateral canal then the patient will experience giddiness and nystagmus could be observed. This is positive fistula test. Examination of external ear and tympanic membrane. Since it provides two and half times magnification examination of ear drum is facilitated Instillation of medications. Medications can be pushed to reach the middle ear cavity through preexisting perforation by filling up the ear canal with medicine and applying pressure using Siegel speculum drtbalu's otolaryngology online

19. Hartmann’s forceps This forceps resembles Tilleys forceps in its angulation. The difference being the tip of this forceps is wide and spade like with serrations. It is used to apply dressings and medicated pledgets into the ear. It can also be used to remove foreign bodies from the ear canal. drtbalu's otolaryngology online

20. Jobson’s horne probe with ring curette drtbalu's otolaryngology online

21. Jobson-horne probe uses Remove wax from the ear Remove foreign body from ear and nose Removal of granulations in the ear The pointed and serrated end also known as the probe end can be used to probe polyp in the nose and ear after rolling a cotton wisp over it The probe end can be used as cotton swab carrier and can be used to clean the ear or nose drtbalu's otolaryngology online

22. Ear Vectis with cerumen spud Has a ring Vectis and a blunt curette Used to remove wax Used to remove FB from ear / nose drtbalu's otolaryngology online

23. Barany Noise Box Barany Noise box is a standard for masking while performing bone conduction audiogram testing. This instrument provides a broad band noise. Of course there may be a dip in certain frequencies. Maximum sound output varies from one box to the other, but at the most 90 dB can be generated when it is held over the ear. These levels of noise are sufficient to mask one ear for all practical purposes. The only danger being that sound can travel around the skull to the test ear as well thereby masking it too. Nearly 80% of normal ears will be masked by a Barany's noise box. Sound can be generated by winding the key provided. It works like a clock work mechanism. drtbalu's otolaryngology online

24. Frenzel glasses This spectacle is used to detect the presence of nystagmus in a patient. The lens is about 20 diopters. The patient is made to wear these glasses. It removes optic fixation making the nystagmus more overt. It also provides the tester with a magnified view of the eye which allows easy observation. It also has an illumination bulb for detection of nystagmus. drtbalu's otolaryngology online

25. Tilley’s forceps This is an angled forceps with serrations at the tip of the blades. It can be used in ear as well as nasal cavities. This is a versatile outpatient instrument. Used for nasal packing Used to remove FB/crusts/ debris from nasal cavity Can be used to pack the ear / mastoid cavity during mastoid surgery drtbalu's otolaryngology online

26. otoscope It is held in the hand at the same side of the ear that is being examined Two grips used – pencil & hammer grips Good ear is examined first to prevent infection from infected ear spreading to good ear Speculum chosen should fit snugly into the ear canal drtbalu's otolaryngology online

27. Otoscopy grips (pencil grip) The pencil grip allows the side of your hand to rest on the patient's temple, reducing the risk of trauma if the patient suddenly moves his or her head (this is common when examining young children or patients with tender canals). drtbalu's otolaryngology online

28. Otoscopy grips (hammer grip) It is less satisfactory, however, because you have less control, which increases the risk of inflicting pain by pressing the speculum tip on to the skin of the canal wall. drtbalu's otolaryngology online

29. Otoscope bulb Otoscope insufflator bulb which can be attached to the otoscope. Pressure can be increased at the level of ear drum by just compressing the bulb. Increased pressure would push the ear drum inwards. On releasing the pressure the drum would move outwards. This set up is used to test the mobility of ear drum. drtbalu's otolaryngology online

30. Lac’s tongue depressor In the examination of oral cavity it is imperative on the part of the examiner to depress the tongue. Depression of the tongue is usually performed by lac's tongue depressor. It is usually held in the non dominant hand while leavin the dominant hand free. Used in oral cavity examination Used during post nasal examination drtbalu's otolaryngology online

31. Laryngeal mirror drtbalu's otolaryngology online

32. Postnasal mirror This mirror is angulated The mirror is smaller in size when compared to laryngeal mirror After depressing the tongue using a tongue depressor this mirror is slide underneath the soft palate thereby visualizing the reflection of postnasal space drtbalu's otolaryngology online

33. Tuning forks In ENT, tuning forks are used to clinically test hearing and identify the type of hearing loss. The parts of a tuning fork are: Base plate or footplate Shaft Prongs that vibrate producing sound If you look at the shaft or the footplate closely, you will find it carries a number - this is the frequency at which the tuning fork vibrates and is denoted in Hertz (Hz). The commonly used tuning forks to test hearing are 256 Hz, 512 Hz and 1024 Hz. These frequencies correspond to the speech frequencies. drtbalu's otolaryngology online

34. Kramer Aural speculum Ear examination started with a "shoe horn" model speculum. This was followed by bivalve / trivalve specula which was used for all body cavities. The first scientific ear examination was conducted with a bivalve specula. Two models were famous those days. The first one being Itard and the other one being Kramer. Wihelm Kramer devised this bivalved speculum to examine the ear canal. Kramer speculum is the mother of all bivalve speculum and the currently used Hartmann's speculum is a modification of Karmer's speculum. When closed the blades of kramer's speculum forms a conical tube split into two halves through its long axis. Each half mounted upon one end of a forceps blade. The blades are kept closed by a spring and can be opened to any desired extent by pressure on handles. The blades are usually thin about one and a half inches in length and 4 mm in breath. The internal diameter would be about 12 mm at its base. drtbalu's otolaryngology online

35. Bonafont speculum This bivalve speculum was designed by Dr Bonafont . This speculum was used to examine both ear and nasal cavities. This instrument is made of chormed steel and is conical in shape. The size of the tip of the cone is adjustable because of the presence of two trough like blades. These two blades form the entire speculum's form. At the fulcrum these blades flare outwards slightly thereby allowing room for expansion. An U shaped strip of metal surrounds the flange. This metal is attached to the blade at two points and is run through with a threaded rod. The speculum's degree of expansion can be increased or decreased by altering the distance between the U shaped component and the blade. It has a circular knob and is finely grooved. The speculum is 2 inches long and one and half inches at its widest point. Since this speculum is self retaining it allows both hands of the surgeon free to perform aural / nasal surgeries. drtbalu's otolaryngology online

36. TRAUTMANN MYRINGOTOME This is used to perform myringotomy It is bent at 45 degrees ensuring that visibility is not obstructed Tip is pointed and sharp Blade is pointing downwards so that the ear drum could be cut in a downward direction drtbalu's otolaryngology online

37. Politzer myringotome Used to perform myringotomy It has only one angle as compared to that of Trautman’s myringotome drtbalu's otolaryngology online

38. Krause ear snare Used to snare out aural polyp It is safer than avulsing the polyp as it could be attached to vital middle ear structures like ossicles and facial nerve The polypoidal mass is engaged inside the wire loop and is avulsed drtbalu's otolaryngology online

39. Hartmann’s aural dressing forceps This is an angled double action micro forceps Tip is pointed and serrated Used to hold cotton balls before aural packing Commonly used in middle ear surgeries drtbalu's otolaryngology online

40. Wilde's speculum This speculum is made of silver. It has a simple truncated design. It is milled at the proximal end in order to ensure that it does not injure the skin of the external auditory canal. Originally it was manufactured in three sizes and was supplied with an unique case. Once inserted this speculum would straighten the external auditory canal making visualization of ear drum that much easier. This speculum is not self retaining but if a snugly fitting one is chosen then it will hold on to the external auditory canal allowing both hands of the surgeon free to perform the surgery. This is one of the earliest aural speculums to be designed and served as an inspiration of other design changes that followed. drtbalu's otolaryngology online

41. Gruber aural speculum Gruber speculum differs from other similar specula especially the politzer in that their tip is oval in shape. This shape has an advantage as it conforms more closely with that of the shape of the normal ear canal and hence, they seat well inside the ear canal. Since this speculum is snugly fitting it cannot be rotated. Some surgeons believe this to be a disadvantage because rotation movement facilitates introduction. It comes in three sizes. size 1 (4mm x 5mm) size 2 (5mm x 6mm) size 3 (6mm x 7mm) drtbalu's otolaryngology online

42. Tumarkin’s slotted aural speculum Tumarkins Slotted Aural speculum has a slot. This slot is a complete one, extending throughout the length of the speculum. This slot helps the surgeon to infiltrate the external auditory canal with local anesthetic before ear surgery. By rotating the ear speculum the slot also moves facilitating infiltration of local anesthetic medicines. The speculum should be inserted up to the cartilaginous portion of the external auditory canal. It should not touch the bony portion of the external auditory canal since it would cause more pain. drtbalu's otolaryngology online

43. Rosen’s aural speculum This aural speculum was designed by Rosen the renowned otologist. It is partially slotted where the slot does not extend up to the tip of the speculum. The slot extends to up to 3/4 the length of the speculum. The absence of slot close to its tip helps the speculum to snugly fit into the external auditory canal. It also straightens the external canal making the tympanic membrane visible to the surgeon. The presence of slot helps the surgeon to infiltrate local anesthetic medicines to the external auditory canal. This speculum should be introduced only up the cartilaginous portion of the external canal. It should not touch the bony portion of the external auditory canal. drtbalu's otolaryngology online

44. Holmgren adjustable aural speculum This is a self retaining adjustable aural speculum. Its flanges resembles more or less a Duck's bill. The flanges can be made to move apart by tightening the screw provided for this purpose. Hence this speculum can be used for surgical procedures involving the ear. Since it is self retaining, it can stay in a position allowing the surgeon to have both his hands free to perform the surgical procedure. This speculum straightens the external auditory canal and also holds the cartilaginous portion of the external auditory canal wide apart making it easy to visualize the tympanic membrane. drtbalu's otolaryngology online

45. Hartmann's aural speculum Hartmann aural speculum is funnel shaped and has no slit in its body. The outer end of the speculum is thickened to provide better grip. The aural end of the speculum is slanted to match the position of the ear drum. It is available in 4 different sizes to suit different dimensions of external auditory canal. drtbalu's otolaryngology online

46. Shea's aural speculum This is a non self retaining aural speculum. It does not have a slit in its body. The aural end of the speculum is beveled in order to match the angulation of the ear drum. This speculum straightens the external canal and also holds the cartilaginous portion of the external canal apart enabling the ear drum to be visualized better. Shea designed this speculum to perform stapedectomy where visualization of the postero superior portion of the tympanic membrane is a must. drtbalu's otolaryngology online

47. Lucae aural forceps Lucae curved aural forceps is a bayonet shaped instrument used to pack or unpack the external auditory canal. Its shape ensures an unobstructed view of the field while working. drtbalu's otolaryngology online

48. Eustachean tube catheter It is a metallic catheter with a curved proximal end and a ring at its base. The opening of its curved proximal end is at its tip. This instrument is usually 12 - 15 cms long. Ring on the distal end indicates the direction of the tip of the catheter. This is not used commonly these days as atraumatic equipment can be used to test eustachean tube patency. I personally use it to remove nasal FB drtbalu's otolaryngology online

49. Politzer bag This apparatus is used to insufflate the eustachean tube. Components of this apparatus include: Rubber bulb Nozzle Rubber tube Nose piece drtbalu's otolaryngology online

50. How to use Politzer bag? The rubber tube is connected to the nozzle and the nose piece is fixed inside the nasal cavity on the side of the eustachean tube to be tested. The other nostril is closed to prevent air leak. The rubber bulb is pressed, and the patient is asked to swallow. The ear under test is auscultated using a stethoscope place over it. Hissing can be heard by the examiner if the eustachean tube is patent. The same procedure can be performed to ventilate the middle ear cavity. drtbalu's otolaryngology online

51. Politzer's spoon forceps Politzer's spoon forceps is a spring type forceps. The shanks are bent at an angle of 45 degrees. The blades are slender and each of the two blades terminate in a long spoon shaped jaw which has finely serrated edges. Since the maximum width of this forceps is less than 3 mm it can be used through a speculum of the smallest size. The blades are constructed in such a way that they will not cross or pass by each other and hence will not obstruct surgeon's field of vision. drtbalu's otolaryngology online

52. Plester self retaining hemostatic masoid retractor This retractor is smaller in size when compared to that of mollison retractor. Middle teeth of one prong is slightly longer. This can be used to retract external canal wall skin for better visualization. 1. Used in mastoid surgeries to visualize the external canal and middle ear cavity 2. Can be used in endaural surgeries (mastoidectomy) is classic end aural retractor is not available 3. The pressure applied by the prongs to the soft tissue keeps the operating field dry because of its hemostatic effect drtbalu's otolaryngology online

53. Mollison self retaining hemostatic mastoid retractor This self retaining retractor is used commonly in mastoid surgeries. drtbalu's otolaryngology online

54. Mollison retractor Uses: 1. To Harvest temporalis fascia graft 2. To expose the mastoid cortex and hold the soft tissue apart 3. In difficult neck surgical procedures where two hands need to be free 4. In surgeries involving the skull drtbalu's otolaryngology online

55. Jenson's Retractor This small retractor is used in mastoid surgeries commonly. It has three prongs of uniform size. The retractor can be applied by turning the thumb screw. When used in combination with Mollison's retractor it improves exposure during mastoid surgeries. Can be used in thyroid surgeries also drtbalu's otolaryngology online

56. Perkin's self retaining hemostatic mastoid retractor This retractor has three prongs of equal sizes in one blade and a single flat broad prong on the other blade. The single flat broad prong is useful in retracting skin away from the surgical site. It is very useful in retracting canal skin during ear surgeries. drtbalu's otolaryngology online

57. Farabeuf mastoid periosteal elevator This periosteal elevator is used in mastoid surgeries to elevate and strip periosteum from the mastoid process. It is held in the dominant hand with index finger resting on the ridged portion. The tip of the elevator is bent forwards and is sharp. drtbalu's otolaryngology online

58. Spratt Brun Mastoid currette This currette is used during mastoid surgeries in the olden era. Classically it is used to widen the aditus. Widening of aditus is usually performed in the posterosuperior direction. The base of the handle of the currette is held within the palm of the dominant hand and the currette is stabilized with the index finger. drtbalu's otolaryngology online

59. Rosen’s knife Used to incise external canal wall skin in order to raise tympanomeatal flap Used in myringoplasty Used in stapedectomy Used in other middle ear surgeries drtbalu's otolaryngology online

60. Plester flag knife (flap knife) This is a micro ear instrument used to make a horizontal incision on the external canal wall skin during elevation of tympanomeatal flap. It is also used to elevate tympanomeatal flap hence is used in middle ear surgeries like myringoplasty, tympanoplasty and ossiculoplasty. drtbalu's otolaryngology online

61. Troeltsch aural forceps This forceps can be used both in ear and nose. It can be used to pack the ear and nose. It can be used to pack and unpack cavities It can be used to introduce medicated dressing into nose / ear drtbalu's otolaryngology online

62. Hartmann micro alligator forceps Single action micro alligator forceps Used in middle ear surgical procedures Used to hold the cotton ball before insertion into the ear cavity drtbalu's otolaryngology online

63. Wullstein micro cup forceps Single action micro cup forceps Distally has a 0.9 mm oval cup It is available in three forms: straight upturned Downturned Used in middle ear surgeries drtbalu's otolaryngology online

64. Maceven’s antrum seeker While doing mastoid surgery antrum and its aditus is identified using this instrument It has a bent probe at one end which is used to identify the antrum It has a small curette at the other end which can be used to widen the aditus drtbalu's otolaryngology online

65. Trautmann’s mastoid gouge Before the advent of electric drills mastoid surgeries were performed using mallet and gouge. The commonly used gouge was Trautmann's mastoid gouge. Its edge is sharp and rounded. This sharp rounded structure helps to chisel the mastoid crotex with precision. drtbalu's otolaryngology online

66. Lucae Mallet This mallet is used to strike the mastoid gouge during mastoid surgeries. The head of the mallet is specifically rounded in such a way that it will not slip when the gouge is struk drtbalu's otolaryngology online

67. Jenson periosteal elevator This instrument is used to elevate periosteum over mastoid cortex before drilling. This instrument is held between the index finger and thumb while elevating the periosteum drtbalu's otolaryngology online

68. Lempert curette This curette is available in various sizes This instrument was used to curette out the bone to expose the mastoid cavity during the predrill era It is usually held like a dagger in the dominant hand while curetting. While curetting out bone in critical areas index finger may be used as a guide to minimize damage to adjacent structures drtbalu's otolaryngology online

69. Boyle davis mouth gag drtbalu's otolaryngology online

70. Draffins bipod and Maguran's plate This instrument is used to hold mouth gags in position during oral cavity surgeries. It has two components: Horizontal slotted rod which is known as Maguran's plate. The lower end of bipod slides into these holes. Two vertical rod with rings. They are known as Draffin pods. These rings can be slid over tongue blade and the lower end can be anchored by passing it over one of the holes in the Maguran's plate. This plate is usually placed under the neck of the patient. drtbalu's otolaryngology online

71. Yankauer's Suction Yankauer's suction tip is commonly used in sucking out oropharyngeal secretions. This suction tip is used in tonsillectomy and other oropharyngeal surgical procedures to suck blood and secretions. This suction catheter was designed by Sidney Yankauer of New York. He was an otolaryngologist by profession. This suction catheter is available in two forms Metal and disposable plastic. It has a unique curvature which mimics the curvature of the oropharynx. Its tip is blunt and guarded and hence does not cause mucosal trauma while suctioning. Plastic suction catheters have safety vent which needs to be occluded to increase suctioning effect. There are instances during emergencies the physician has failed to occlude the safety vent of the disposable plastic suction catheter there by causing reduced suctioning effect which had hindered the patient's treatment. drtbalu's otolaryngology online

72. Kilner Doughty mouth gag This is a modification of Boyle Davis mouth gag. As shown in the picture the tongue blades have slots in the middle. These slots will be useful if oral intubation is preferred in a child posted for adenotonsillectomy due to the presence of enlarged adenoid. Anesthetist is requested by the surgeon to perform oral intubation and leave the endotracheal tube in midline. While introducing the tongue blade with the mouth gag it is ensured that the endotracheal tube is held within the slot of the tongue blade. This ensures that the endotracheal tube's lumen is not compressed when gag is applied. drtbalu's otolaryngology online

73. Dennis Brown Tonsil holding Forceps Dennis brown tonsil holding forceps is used to hold and medialize tonsil during tonsillectomy surgery. Its tip is curved and toothed. The curvature enables tonsil to be held without obstructing the vision of surgeon. It has an incomplete ring on one of its arms (indicated by an arrow). Through this ring snare wire can be passed to snare the tonsil out. It also has a locking mechanism. Once locked the tonsil tissue will be held firmly within its prongs. drtbalu's otolaryngology online

74. Muck's Forceps This forceps is used to grasp the tonsil and pull it medially during tonsillectomy. It is particularly useful in grasping in small fibrotic tonsils. It is also useful in removing tonsillar remnants after tonsil removal. Fibrotic tonsils are difficult to hold with other types of tonsil holding forceps. drtbalu's otolaryngology online

75. Mollison's pillar retractor with Dissector This instrument is used to separate tonsil from its capsule. This instrument is used to retract the anterior pillar for better visualization of tonsillar fossa after removal of tonsil. This will ensure complete visualization of fossa to look for any bleeding. The dissector end can be used to dissect the tonsil out of its bed. It can also be used to retract soft palate and uvula. drtbalu's otolaryngology online

76. Waugh's Tenaculum Forceps This instrument resembles a toothed forceps. It is finer and slightly longer. The toothed end of the forceps is used to incise mucosa over the anterior pillar of tonsil in order to lift the tonsil out of its fossa. drtbalu's otolaryngology online

77. Metzenbaum scissors These are surgical scissors designed to cut delicate tissue and blunt dissection. This scissors come in varying lengths and the longer one is used in tonsillectomy. The name Metzenbaum derives from its designer Myron Firth Metzenbaum an American surgeon who specialized in oral and reconstructive surgery. Using this scissors mucosal incision for tonsillectomy can be made with precision. This same scissors can be used to cut the silk after bleeder from the tonsillar fossa has been tied. It comes in two forms: Curved - This is commonly used in tonsillectomy. The advantage of the curved tip is that the tip will always be visible to the surgeon while he is working in the tonsillar fossa. Straight - This is not commonly used in tonsillectomy procedures drtbalu's otolaryngology online

78. Eve's snare Eve's snare is used to snare the tonsil. Snaring the tonsil crushes the pedicle thereby reducing the bleeding. The crushed tissue also releases coagulation factors thereby hastening the coagulation process. This snare was designed by a female surgeon named Eve. drtbalu's otolaryngology online

79. Negus knot adjuster Negus knot adjuster is used to adjust and tighten the suture knot over the tonsillar fossa bleeder. The tip of the instrument can be used to push the knot till the end to reach the bleeding point before tightening the knot. drtbalu's otolaryngology online

80. Brickett's forceps These are long forceps that can be locked. The tip of these forceps are pointed. It comes in two flavors. 1. Straight artery forceps 2. Curved artery forceps The straight forceps is used to pick the bleeding point. The straight forceps is used to hold cotton ball that needs to be placed in the tonsillar fossa while tonsil tissue is being dissected Curved forceps is used to hold the bleeder precisely before applying silk ligature drtbalu's otolaryngology online

81. Physick Tonsillotome Physick Tonsillotome was first devised by Physick an American surgeon. The tonsillar tissue is held within the opening at the proximal end of this instrument. On pressing the level the knife will severe the tissue. drtbalu's otolaryngology online

82. St Claire Thompson Adenoid Curette Adenoidectomy could be performed using St.Clair Thompson adenoid curette. It is held like a dagger in the operating hand. There are 2 types of adenoid curettes i.e. one with a cage and other without it. If one with cage is available, the cage can be dismantled and used as a curette without cage. The cage holds the adenoid tissue preventing aspiration into the lungs. Adenoid curette without cage is used to remove remnant adenoid tissue as well as tubal tonsils since it causes minimal trauma to the tissue. Using the curette with cage to remove the tubal tonsil may traumatize the pharyngeal end of the tube causing permanent damage to the middle ear ventilation. Both these instruments should be held in the dominant hand like a dagger. The head of the curette is passed under the soft palate. After it has engaged with the adenoid tissue, the head of the patient is stabilized with the non dominant hand of the surgeon. The adenoid tissue is scooped out by a inferior to superior motion of the hand. This is actually a blind procedure. Vision can be assisted by prudent use of Dental mirror introduced under the soft palate or by using a wide angled rigid endoscope. drtbalu's otolaryngology online

83. Lawforce Adenotome This instrument comes in various lengths with blades of different sizes. It is passed under the soft palate. It is then placed in such a way that it traps the adenoid tissue in the nasopharynx within its cage. The tissue is then cut by pushing the plunger. This instrument works like a tonsillar guillotine. drtbalu's otolaryngology online

84. St Claire Thompson Adenoid Tag forceps This is a non-through cutting forceps. This forceps is used to remove adenoid tags from the post nasal space following adenoidectomy. This forceps can also be used to remove post nasal packs. drtbalu's otolaryngology online

85. Gwynne Evan Tonsillar dissector This instrument is used to dissect out the tonsil from tonsillar fossa. It has a blunt end and a serrated end. The blunt end is used for the initial dissection of tonsil and to ensure that a proper plane is obtained. The serrated end is used to cut the tissues from the upper pole, pillars and the tonsillar bed till the lower pole is reached. drtbalu's otolaryngology online

86. Tilley Lichtwicz trocar and canula drtbalu's otolaryngology online

87. Freer's elevator Freer's elevator was designed by Otto Freer of Illinois Chicago. While he developed this elevator he relied heavily on dental instrument designs. This instrument a fairly simple one will enable the surgeon to elevate mucoperiosteal flap of nasal septum during septoplasty / submucosal resection of nasal septum. This instrument has a dull finish in order to prevent it from unnecessarily reflecting light during the surgical procedure. It comes in two versions i.e sharp and blunt ones. Sharp one is ideally used to initially elevate the mucoperichondrial flap. After the flap is elevated a little bit the blunt version of the elevator can be used to proceed further. The same instrument has both blunt and sharp edges on either ends. All the surgeon has to do is to reverse the instrument to get the desired effect. It also comes in various lengths. This elevator is best used to perform dissection at the interface between a hard structure and soft tissue. Freer in fact used this instrument to dissect nail out of the nail bed and also to strip periosteum from the bone. drtbalu's otolaryngology online

88. Killian's Elevator This elevator is used to elevate mucoperichondrial flap in submucous resection of nasal septum. Both ends of this elevator is sharp and slightly curved. The curvature helps in application of pressure over nasal septal cartilage while elevating the flap. This instrument is used to deepen the incision and to elevate the flap during submucous resection of nasal septum. While using this instrument care should be taken to ensure that the curved tip faces the septal cartilage. This elevator is also used in rhinoplasty surgeries to elevate perichondrial flaps. drtbalu's otolaryngology online

89. Killian Mucoperichondrial elevators This is a bayonet shaped instrument with a thumb rest. One side of the elevator is flat and the other side is convex. While the flat side faces the septum, the convex side faces the mucoperiosteal flap and the thumb rest faces upwards. Hence, this instrument is separate for right and left sides of the septum. drtbalu's otolaryngology online

90. Cottle's Elevator This elevator is used to elevate mucoperichondrium of nasal septum during septal surgeries. It has a curved elevator at one end and is broad at the other end. This broad end can be held conveniently by the surgeon. This elevator should be used with the curvature facing the nasal septum. This will ensure that pressure is applied to the firm surface of nasal septum while attempting to elevate the flap. drtbalu's otolaryngology online

91. Howarth septal elevator This instrument has a blunt and sharp end for septal surgeries. The blunt end is used for mucoperichondrial / mucoperiosteal elevation. The sharp side is spade shaped and is used to elevated the septum anteroinferiorly from the maxillary crest. drtbalu's otolaryngology online

92. Joseph Elevator This elevator is used to elevate mucoperichondrium and mucoperiosteum during septal surgeries. It has one sharp end which is slightly curved. Broad end is used for holding the instrument. The curvature should be pointing towards the nasal septum during septal surgeries. drtbalu's otolaryngology online

93. Killian's Bayonet shaped gouge The Killian's nasal gouge is bayonet shaped. Its shaft is bent in such a way that the tip lies on a higher plane than the handle. This ensures that the hand holding the instrument does not block the vision of the operating surgeon. The surgeon can constantly visualize the tip of the instrument inside the nasal cavity. The tip of the instrument is U shaped and is very sharp. This helps in removal of spurs and sharp projections during septal surgeries. Its broad handle can be hit conveniently using a mallet. drtbalu's otolaryngology online

94. Tilley Nasal septal gouge This is a bayonet shaped nasal gouge resembling Killian nasal gouge. The only difference being that its tip is V shaped for better anchorage of maxillary crest. It is used to chisel out maxillary crest deviations. The unique shape ensures that the tip of the gouge is not blocked by the surgeon’s hand during surgery. The V shaped tip can be engaged at the maxillary crest and the bone can be chiselled out by a sharp tap with a mallet at the broad end of the gouge. drtbalu's otolaryngology online

95. Heath Mallet This mallet has a cylinder-shaped head. Its handle is short and grooved. The grooves in the handle ensures better grip for the surgeon ensuring that it does not slip and fall during the surgical procedure. The mallet can be used to hit the gouge and remove spur and bony / cartilaginous deviations of nasal septum. It is also used in rhinoplasty procedures to chip away bone in an attempt to reshape them. drtbalu's otolaryngology online

96. Ballenger Swivel Knife This knife can rotate 360 degrees within its two prongs. This instrument is used in submucous resection of nasal septum. The tip that rotates 360 degrees on itself helps in complete resection of cartilaginous septum. Its angulation ensures that the tip of the knife is not obstructed by the hands of the surgeon during the procedure. drtbalu's otolaryngology online

97. Killian Curved Suction Tip This suction tip is used in FESS. It is ideal to suck out secretions from maxillary sinus antrum. It can also be used to remove fungal debris from the maxillary sinus antrum. This suction tip can also be used to enter frontal sinus ostium in order to suck out secretions. Its blunt tip ensures that it does not cause trauma to nasal and sinus mucosa while suction is being applied. drtbalu's otolaryngology online

98. Weil Blakesley straight cup forceps This single action forceps is a common instrument used in functional endoscopic sinus surgery. It is used to remove bulla ethmoidalis and other ethmoidal air cells. It can also be used to remove small bone chips from the nasal cavity during endoscopic sinus surgical procedures. It can also be used to remove polypi from nose. All forces used in endoscopic sinus surgery have a distal hinge and the blades only open at the tip of the instrument. This ensures that the lever advantage and the strength of the instrument resides at its tip. It also limits the opening capacity of the instrument distally thus making it accessible at the narrow spaces within the nasal cavity. The advantage of single action forceps is that it is more stable and stronger than double action forceps. The major disadvantage of single action forceps is that the space between the blades of forceps is rather limited. It has an eye at its upper jaw to permit proper visualization of tissue. drtbalu's otolaryngology online

99. Kerrison punch This is a back biting forceps It has a distal action Used to bite the anterior maxillary process in order to expose lacrimal gland and is used in endoscopic DCR surgeries drtbalu's otolaryngology online

100. Blakesley Thru-cut Forceps This instrument is used in Endoscopic sinus surgery. The tip of this forceps is rather interesting. Lower lip of this single action forceps has a hold inside which tissue that is to be cut can be held. The upper jaw which is mobile has sharp margins which cuts the tissue held in the lower jaw opening rather cleanly. drtbalu's otolaryngology online

101. Ash & Walsham forceps These instruments are widely used in facio maxillary surgery. In otolaryngology these instruments are used to reduce fractures involving nasal bones and nasal septum. Ash forceps is used to straighten a fractured / buckled nasal septum. The tip of the Ash forceps is slightly angled upwards. It is slide between the septum (on either side) and the buckled septum is lifted up holding the forceps in a double handed fashion (one hand above the other). The Walsham forceps is used for closed reduction of fracture nasal bones. One lip of the forceps is guarded with a rubber sleeve in order to prevent injury to skin overlying the nasal bone. During the process of reduction the forceps is inserted into the nasal cavity in such a way that its guarded lip is outside and its other lip lies underneath the nasal bone. The fractured nasal bone is disimpacted and re positioned. drtbalu's otolaryngology online

102. Punctum dilator It has a cylindrical corrugated metal handle with conical pointed tips on both sides, one tip larger than the other. It is used to dilate the punctum and canaliculus during sac syringing in dacryocystitis. The smaller tip is used to cannulate the punctum while the larger one is used to dilate it. drtbalu's otolaryngology online

103. Heuwieser forceps As a surgeon you would have faced tremendous difficulty during endoscopic sinus surgery while attempting to remove a polyp from maxillary antrum through the natural ostium you have widened. In fact it will be virtually impossible to remove polyp from the roof and anterior wall of maxillary antrum via the natural ostium. With the introduction of Heuwieser forceps this job has become simple. The jaw of this forceps is highly versatile that it opens backwards up to 120 degrees. It has a working length of 130mm. It is used for: Removal of tissue from maxillary sinus Endonasal removal of cysts and polypi Removal of foreign bodies from hypopharynx drtbalu's otolaryngology online

104. Trousseau Tracheal dilator In 1833 Armand Trousseau designed this instrument to dilate the incision into the airway to allow easy passage of tracheostomy tube. This instrument is held in the palm of the hand and the curved tip is inserted into the soft tissues in the neck. The dilator can be dilated by bringing both limbs together using the palm of the hand. It is actually not a dilator it is a retractor used to retract soft tissues of the neck to expose the trachea during tracheostomy tube insertion. drtbalu's otolaryngology online

105. Killian’s self retaining nasal speculum In all nasal septal surgeries the killian's long bladed self retaining nasal speculum is used to visualize the interior of the nose. Its self retaining nature frees up both the hands for surgery. drtbalu's otolaryngology online

106. Higginson’s syringe After performing antral puncture, a Higginson's syringe is used to wash the antrum. It has a bulb which helps to suck the saline and there is a oneway valve which prevents back flow. Pressure is applied to the bulb to eject the fluid from the syringe. drtbalu's otolaryngology online

107. Fuller’s tracheostomy tube Fuller's tracheostomy tube showing its two parts, outer tube which has two flanges and the longer inner tube with a opening at its shoulder known as the speaking valve. The only disadvantage of this tube is that the patient cannot be connected to a ventilator if this tube is used. The main advantage of this tube is to bypass the obstruction. It also reduces the physiological dead space. Bronchial toileting can also be performed through this tube. drtbalu's otolaryngology online

108. Jackson tracheostomy tube This is a metal tracheostomy tube It has an outer and inner tube It is provided with an obturator which facilitates easy introduction Its curvature resembles the curvature of the trachea and the curvature is known as Jackson’s curve drtbalu's otolaryngology online

109. Portex tube Cuffed tube Single lumen tube Has a cuff and hence can be connected to a ventilator It cannot be occluded as it does not have a speaking valve hence tube change is needed at the time of decannulation Patient will not be able to speak while this tube is used A separate speaking valve attachment can be used to enable the patient to speak drtbalu's otolaryngology online

110. Oesophagoscope rigid Roberts - Jesberg esophagoscope: Available in following lengths: 50,45,40,35 and 30 cms Has different types of illumination Distance from the incisor is marked on the scope Distal end is beaked bluntly to prevent damage to esophageal mucosa Uses: FB removal Biopsy drtbalu's otolaryngology online

111. Oesophagoscopy forceps Alligator forceps with double action serrated jaws used to remove hard FB like dentures Pointed and serrated forceps to remove coins and flat FB Grasping forceps to remove peanuts Universal forceps for biopsy and FB removal drtbalu's otolaryngology online

112. Bronchoscope It has holes in its lower third to ventilate the opposite lung while scopy is being performed It has a suction and oxygen port Types of illumination include proximal, distal and circumillumination drtbalu's otolaryngology online

113. Bronchoscopy forceps Grasping forceps used to grasp FB Single action forceps to remove thin FB Alligator forceps used to remove linear FB Biopsy forceps to take biopsy of suspicious looking lesions drtbalu's otolaryngology online

114. kleinsasser operating laryngoscope This is also known as suspension laryngoscope The laryngoscope is attached to a chest piece that rests on the chest of the patient It allows the surgeon’s hands free for surgical procedures This instrument is used to perform microlaryngeal surgeries drtbalu's otolaryngology online

115. Bruning syringe Used for injecting Teflon gel into vocal folds Used for injecting fat into vocal folds Injecting Teflon / fat adds bulk to the vocal folds drtbalu's otolaryngology online

116. Useful android resources Imaging in rhinology drtbalu's otolaryngology online

117. Instruments in otolaryngology drtbalu's otolaryngology online

118. Otolaryngology resources all in one drtbalu's otolaryngology online

119. drtbalu's otolaryngology online Thank you