ENT Surgery

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What are the three main regions of the ear?

Outer, middle, and inner ear.

Outer ear

Comprised of the pinna (auricle) and the external auditory canal (meatus). The auricle is the portion of the ear that is visible on each side of the head; it encircles the opening into the external auditory meatus which extends from the pinna to the tympanic membrane. The canal is covered with epithelium, lined with fine hairs, and houses the ceruminous glands which secrete cerumen (earwax).

Tympanic membrane

Also known as the eardrum, is the separation between the outer and middle ear. It is composed of 3 layers: The outer surface is covered w/epithelium, the central layer is fibrous connective tissue, and the inner lining is mucous membrane. It is disk shaped, normally concave, and has a diameter of 1 cm. It is normally a pearly gray in color, translucent, and has a shiny appearance.

Middle ear

Also known as the tympanic cavity, is an air filled chamber located within the temporal bone. It is lined with a mucous membrane, which is a continuation of the inner layer of the tympanic membrane. The tympanic cavity houses a series of three tiny bones called auditory ossicles. From lateral to medial there named: malleus (hammer), incus (anvil), and the stapes (stirrup).

Malleus (hammer)

Articulates with the incus and is attached to the tympanic membrane (eardrum), from which vibrational sound pressure motion is passed.

Incus (anvil)

The middle bone which is connected to the other two, passes vibrations onto the stapes.

Stapes (stirrup)

Articulates with the incus and is attached to the membrane of the fenestra ovalis, the elliptical or oval window or opening between the middle ear and the vestibule of the inner ear.

Mastoid sinus

The air cells of the mastoid sinus are located behind the auricle within the mastoid process of the temporal bone.

Inner ear

Inner ear, or labyrinth, consists of two main sections: The bony osseous or perilymphatic labyrinth and the membraneaous labyrinth. Labyrinths are complex series of canals and chambers located within the petrous portion of the temporal bone. A fluid called perilymph fills the spaces of the bony labyrinth, which is lined by a thin membrane that houses another fluid called endolymph.

Vestibule

The central part of the osseous labyrinth, and is situated medial to the tympanic cavity, behind the cochlea, and in front of the semicircular canals.

Semicircular canals

The passages in the inner ear, in the bony labyrinth concerned with the sense of balance, especially the detection of movement. Each ear has three semicircular canals (anterior, lateral and posterior) situated approximately at right angles to each other. They contain the semicircular ducts.

Cochlea

Auditory portion of the inner ear. Its core component is the Organ of Corti, the sensory organ of hearing. The cochlea is filled with a watery liquid, which moves in response to the vibrations coming from the middle ear via the oval window. As the fluid moves, thousands of "hair cells" are set in motion, and convert that motion to electrical signals that are communicated via neurotransmitters to many thousands of nerve cells.

Membranous labyrinth

Located within the bony labyrinth, also divided into three parts: semicircular ducts and two saclike structures - the saccule and the utricle.

Semicircular ducts

the membranous tubes housed within the semicircular canals.They have enlarged portions at one end, called ampullae, which contain nerve endings, and which are filled with fluid. The semicircular ducts respond to movement of the head. When the head changes position, the fluid in the duct that lies in the plane of movement also moves but, because of its inertia, the fluid flow lags behind the head movement. Thus the fluid presses against the delicate hairs of the nerves in the ampulla, and these nerves then register the fact that the head is turning in such a direction.

Saccule

The saccule, or sacculus, is the smaller of the two vestibular sacs. The saccule is a bed of sensory cells situated in the inner ear. The saccule translates head movements into neural impulses which the brain can interpret. The saccule is sensitive to linear translations of the head, specifically movements up and down (think about moving on an elevator). When the head moves vertically, the sensory cells of the saccule are disturbed and the neurons connected to them begin transmitting impulses to the brain. These impulses travel along the vestibular portion of the eighth cranial nerve to the vestibular nuclei in the brainstem.

Utricle

The utricle is larger than the saccule and is of an oblong form, compressed transversely, and occupies the upper and back part of the vestibule, lying in contact with the recessus ellipticus and the part below it. These use small stones and a viscous fluid to stimulate hair cells to detect motion and orientation.

Deafness

Any reduction of hearing, no matter how slight.

Conduction-type deafness

Occurs when there is an interference with the transmission of sounds from the external or middle ear, preventing sound waves from entering the inner ear. Many of the causes of conduction-type deafness are treatable with medication, surgery, or sound amplification.

Sensorineural deafness

Also referred to as "nerve deafness". This condition involves the cochlear portion of the inner ear and/or the cochlear division of the acoustic nerve. Little can be done to assist these patients, although some of the newer models of cochlear implants show great promise.

Cerumen

Earwax.

Two common causes of obstruction are...

Excessive earwax, and a presence of a foreign body. The patient may complain of loss of hearing, a feeling of fullness, dizziness, and tinnitus (ringing in the ear). Bony growths, called exostoses, and soft tissue growths, such as polyps, may also occur in the canal causing hearing impairment.

Cholesteatoma

A benign cyst or tumor that fills the mastoid cavity is composed of cholesterol and epithelial cells that is either congenital or occurs as a complication of chronic otitis media; located in the middle ear. Surgical intervention is the only option to correct this condiditon. The procedure is a Mastoidectomy.

Signs and symptoms of Cholesteatoma

Earache, headache, purulent discharge from the ear, hearing loss, dizziness, and weakness of the facial muscle due to damage to the 7th cranial nerve (facial nerve).

Otitis externia

Inflammation of the external auditory canal. A common example is swimmer's ear. Swimmer's ear can be caused by stagnant water and wax in the ear or may be acquired from swimming in contaminated water. The inflammations can be either bacterial or fungal and cause the patient a great deal of pain.

Otitis media

Common acute inflammation of the middle ear, usually initiated by blockage of the Eustachian tube causing an accumulation of fluid which would normally be drained into the the nasopharynx. (Severe ear pain). Decongestants may assist in opening the tube, facilitating drainage of the middle ear cavity.

Otosclerosis

Occurs when there is a bony overgrowth of the stapes. Eventually the footplate of the stapes becomes fixed to the oval window, preventing the normal sound vibrations from entering the inner ear. This progressive disease is hereditary, affecting women more commonly than men and is diagnosed with the assistance of a tuning fork and audiometric exams. Surgical treatment to consider fro this disorder would be stapedotomy or stapedectomy.

Mastoiditis

Considered a complication of acute otitis media. The symptoms which include pain and purulent discharge from the external auditory canal, generally develops 10-14 days following acute otitis media.

Myringotomy

An incision into the inferior posterior portion of the TM with a disposable myringotomy knife, for removing fluid. May be accompanied with polyethylene ventilation tubes, or pressure equalizing (PE) tubes.

Myringoplasty

Is a type of tympanoplasty. 5 classifications, which are determined by the extent of the damage to the eardrum and the middle ear.

Type I

TM, a soft tissue graft is used to repair the eardrum.

Type II

TM & malleus, malleus is removed, & TM graft is placed directly against the remaining portion of the malleus or the incus.

Type III

TM, malleus, and incus are affected. The replacement tympanum is placed directly against the intact stapes, permitting the transmission of the sound to the oval window.

Type IV

All of the ossicles are affected, In addition to the perforated tympanum. The only remaining natural structure of the middle ear is the intact and mobile footplate of the stapes. Only an air pocketed remains as protection for the round window, as the graft rests directly on the stapes footplate.

Type V

Similar to IV, the remaining footplate of the stapes is fixed. All ossicles are removed. A window is made into the horizontal semicircular canal and the tympanic graft seals off the middle ear and provides protection for the oval window.

Mastoidectomy

Removal of the bony partitions that form the mastoid air cells. Would be indicated for cholesteatoma or mastoiditis.

Stapedectomy

Surgical procedure of the middle ear performed to improve hearing with patients with otosclerosis. Done under local anesthesia with compliant patients so that the surgeon using either voice commands or a tuning fork may access hearing restoration. Involved removal of the fixed stapes through a transaural or retroauricular incision which may either be total or partial. This procedure allows the stapes to vibrate normally and some patients may benefit from hearing aids.

Stapedotomy

An alternative procedure to stapedectomy. A small opening is created in the fixed stapes footplate with a small drill or laser. This allows for transmission of sound waves or placement of prosthesis.

Tympanoplasty

Is the surgical operation performed for the reconstruction of the eardrum (tympanic membrane) and/or the small bones of the middle ear (ossicles). Tympanoplasty can be performed through the ear canal or through an incision behind the ear. The surgeon takes a graft from the tissues under the skin around the ear and uses it to reconstruct the eardrum.

Cochlear implants

A prosthetic replacement for the cochlear portion off the inner ear. This type of prosthesis is beneficial for individuals with sensor oriented deafness.

T or F: In ear surgery, the operating table is reversed.

True: The patient's head is placed at the foot of the table, allowing space under the foot portion of the table to accommodate the seated team member's legs to allow for equipment placement.

Nitrous oxide

Causes expansion of the middle ear and can cause dislocation of a tympanic membrane graft. Nitrous oxide use is therefore restricted during reconstructive ear surgery.

T or F: A nerve stimulator should be available for identification of the facial and vestibulocochlear nerves.

True.

What autograft is commonly used for tympanoplasty?

Temporalis fascia, it's used because it is easily accessible and provides a thick, well vascularized graft that easily epithelializes.

What pharmaceutical agents are used during ear surgery?

Local anesthetics (with or without epinephrine), gelfoam, bone wax, antibiotics (systemic and topical- wound irrigation, ointment drops, or suspension), and anti-inflammatory agents.

External nose

The tip is referred to as the apex. The base includes the openings or nares and the root joins the nasal bones to the skull superiorly. The flared lateral wings of the external nose are referred to as ala. The dorsum is between the root and the tip, with the bridge being the upper portion of the dorsum.

Internal nose

The nasal cavity is the interior chamber of the nose and is lined with mucous membrane. It's two outside openings or nostrils are referred to as the external nares. The internal nares are the openings from the nasal cavity into the pharynx. The hard and soft palate form the anterior and posterior floor of the nasal cavity. The ending of the soft palate is the uvula.

The nasal cavity is divided into______chambers.

two; anteriorly the septum is cartilaginous, posteriorly the septum has bony attachments to the ethmoid and vomer bones. The septal cartilage is also known as the quadrilateral cartilage.

Conchae/turbinates

Thin, scroll shaped bony elements forming the upper chambers of the nasal cavity. Provides rapid warming and humidification of air as it passes into the lungs.

Paranasal sinuses

A series of ducts called ostia lead to the paranasal sinuses which are air cavities in the bone surrounding the nasal cavity.

Frontal sinuses

Located within the frontal bone behind the eyebrows, and may be one cavity or divided.

Ethmoid sinuses

Located between the eyes and have a honeycomb appearance.

Sphenoid sinuses

Located directly behind the nose at the center of the skull and may be one cavity or divided.

Maxillary sinuses

Located below the eyes and lateral to the nasal cavity.

Blood supply to the nose

Branches of both the internal and external carotid arteries provide the blood supply to the nose. The main source is the internal maxillary artery, which is one of the terminal divisions of the external carotid. * The ST needs to stay sterile until the patient leaves the room after nasal and oral surgery because the patient may have hemorrhage bleeding and need suction to create an airway. *

Olfaction

The sense of smell. The olfactory bulb is the tip of the first cranial nerve. The most chemoreceptors for olfaction are located in the olfactory epithelium in the most superior region of each nasal cavity just above the superior turbinate near the cribiform plate of the ethmoid bone.

Rhinitis

Inflammation of the nasal mucosa, usually evidenced by excessive mucous production or rhinorrhea. The virus that causes the common cold can contribute to this along with foreign bodies. This is generally unilateral rhinitis and often is not given any further consideration until a purulent discharge appears.

Sinusitis

Inflammation of the mucousal lining of the paranasal sinuses. Sinusitis is considered serious when it becomes chronic and suppurative causing permanent changes in the tissues of the sinus. The common cause is the virus that causes the common cold.

Nasal polyps

Growths that originate from the mucous membrane. Most often develop in patients suffering from allergic rhinitis. The polyp is connected to the mucous membrane by a pedicle. Polyps can be multiple and in some cases, the size and number may cause complete obstruction of the nose. The sense of olfaction is often impaired and in many cases, polyps reoccur following treatment.

Hypertrophied turbinates

Permanent enlargement of the turbinates or nasal conchae may occur as a result of chronic rhinitis. Occasionally the size of the turbinate can be reduced electrosurgically or with the use of sclerosing agent. Often the affected turbinate must be excised.

Septal perforation

The nasal septum may become perforated due to carcinoma, chronic infection, intractable picking, occupational chemical exposure, or substance (cocaine) abuse.

Epistaxis

Nosebleed. Trauma is the main cause. Excessive drying of the nasal mucosa, over-blowing, picking, hypertension, and chronic inflammation can also be contributing factors of epistaxis. Anterior bleeds are easily controlled by direct pressure. Posterior bleeding is more profuse and more difficult to control. Packing and electrosurgery may be need to be performed.

SMR/NSR

Submucous Resection indicates that the mucous membrane lining the nasal cavity will be incised, and the underlying perichondrium or periosteum lifted. Cocaine-soaked cottonoids placed preoperatively are removed. Nostril on affected side is opened with a speculum and an incision is made in the mucous membrane and perichondrium. Cartilage is incised and mucous membrane is elevated with a freer.

Septoplasty

Most often done to straighten a deviated nasal septum, and to improve air flow through the nasal cavity. It is also used to repair a perforated septum or one damaged by trauma.

Rhinoplasty

Considered cosmetic and is performed by the plastic/reconstructive surgeon to change the external appearance of the nose.

Turbinectomy

Used to remove hypertrophic turbinate, usually inferior. Turbinectomy is also achieved with a submucosal approach. The nasal mucosa along the edge of the affected turbinate is incised. All or some of the bones of the turbinate are removed. The mucosa is repositioned and held in place with intranasal packing material. The patient should be observed carefully for postoperative hemorrhage.

Polypectomy

Removal of nasal polyps.

Intranasal Antrostomy

Performed to treat sinusitis or remove recurrent polyps that originate from within the maxillary sinus.

Removal of foreign body

Usually done without anesthesia under direct vision in the doctor's office. This only becomes an OR procedure if the patient requires a general anesthetic.

Internal Maxillary Artery Ligation

Ligation of the internal maxillary artery is a "last resort" type of procedure, as most cases of severe epitaxis can be controlled with internal packing or electrosurgery.

Caldwell Luc

Performed when an antrostomy does not provide adequate visualization. The approach into the maxillary sinus for this procedure is through the canine fossa. To remove diseases portions of the antral wall, evacuate sinus contents, and establish drainage through the nose. Is considered in children prior to the descent of the permanent teeth.

Caldwell Luc

Ethmoidectomy

The ethmoid air cells are destroyed and all affected tissue is removed.

Sinus endoscopy

Can be used as a diagnostic procedure, or can be considered functional. The paranasal sinuses can be accessed with the endoscope using an intranasal approach or external incisions. The main advantages to sinus endoscopy is that the surgery can be focused on the area of concern without damaging the surrounding tissue.

Upper aerodigestive tract

Also known as the throat, is in several individual and specialized structures that works in harmony for facilitate respiration and ingestion of food. The pharynx, larynx, trachea, and esophagus all contribute to this complex anatomical region.

Salivary glands

Secretes saliva - there are 3 pairs of salivary glands that are situated outside the oral cavity. Parotid, submandibular, and sublingual.

Parotid gland

Largest of the three glands located on the lateral sides of the face anterior to the external ear.

What is the main concern when performing surgery on the parotid gland?

The significant concern is the course of the facial nerve, because it travels through the gland dividing the superficial portion from the deeper portion. Majority of benign tumors are located here.

Pharynx

Referred to as the throat, is a tubular structure approximately 5 in. in length. The pharynx serves the respiratory tract by receiving air from the nose and mouth, and the digestive tract as it passes food and liquids. The pharynx is divided into 3 regions; nasopahrynx, oropharynx, and the laryngopharynx.

Waldeyer's ring

The lymphoid elements (pharyngeal, palatine, and lingual tonsils, and the pharyngeal band) contained within the pharynx.

Nasopharynx

Most superior portion (above the palate) of the pharynx. Located posterior to the nasal cavity, it begins posteriorly to the nares and extends inferiorly to the uvula. The Eustachian tubes enter the nasopharynx and it houses the pharyngeal tonsils.

Eustachian tubes

Auditory or Pharyngotympanic, enter the nasopharynx from the middle ear. The function of the Eustachian tubes is to equalize the pressure on both sides of the tympanic membrane, preventing rupture. They open during yawning, chewing, swallowing, and blowing the nose.

Pharyngeal tonsils

Single mass of lymphatic tissue embedded in the mucous membrane of the posterior wall of the nasopharynx. When the tonsils are enlarged they are referred to as adenoids which provide protection against pathogens entering the nose.

Oropharynx

Middle portion of the pharynx, located posterior to the oral cavity, Houses the palatine and lingual tonsils. The vestibule is the space between the lips and teeth. During swallowing the nasopharynx is protected by the soft palate, which moves upward to seal off the nasopharynx, directing food and liquids downward.

Palatine tonsils

Are the 2 oval masses of lymphoid tissue commonly called "the tonsils". Produce lymphocytes.

Laryngopharynx

Or hypopharynx, is the inferior portion of the pharynx. It begins at the level of the hyoid bone and extends to the lower margin of the larynx.

Larynx

Voice box, located between the pharynx and the trachea. The largest and most superior of the single cartilage is the thyroid cartilage, Adam's Apple. The cricoid cartilage is the only cartilage in the upper digestive tract to form a complete circle and is found at the base of the larynx. It is the most inferior of the laryngeal cartilages and attaches to the trachea. During swallowing, the superior movable portion of the epiglottis fold over the opening into the larynx, called the glottis.

Glottis

Superior opening into the larynx (space between the true vocal cords). True vocal cords (lower) are capable of vibration when air passes through them during exhalation to produce sound. Fibrous bands that stretch across the hollow interior of the larynx.

Trachea

Windpipe, joins the cricoid cartilage of the larynx to the main stem or primary bronchi leading to each lung. The most inferior tracheal cartilage is called the carina, which bifurcates into the 2 primary bronchi.

Tracheotomy

An incision made into the trachea through the neck below the larynx to gain access to the airway.

Esophagus

Inferior to the laryngopharynx and posterior to the larynx in the mediastinum. The esophagus passes through the diaphragm at the level of the hiatus and is joined to the stomach by the lower esophageal, or cardiac sphincter.

Pharyngitis

Inflammation of the throat, which may be either viral or bacterial in origin. Streptococcal pharyngitis (strep throat) is the most common. Bacterial pharyngitis is diagnosed with a throat culture.

Epiglottitis

Infectious disease that can affect any age group, although it's most commonly seen in 2-5 yr olds. May be viral or bacterial. The most common bacterial agent responsible is Haemphilus influenzae.

Acute epiglottitis

Characterized by a sudden onset of obstruction of the respiratory tract that progresses very rapidly. The cardinal sign is the presence of a "cherry-red" epiglottis. The patient is often in respiratory distress. Any manipulation of the area may increase the inflammation or induce a laryngospasm causing total airway occlusion. If the airway becomes obstructed, endotracheal intubation or tracheotomy may be indicated. Failure to diagnose and respond quickly to this condition results in a 20% death rate.

Tonsillitis

May affect the pharyngeal, palatine, or lingual tonsils. Tonsillitis usually refers to the palatine tonsils and it is the palatine tonsils that are removed during the procedure (tonsillectomy). Most often caused by streptococcal organisms. Failure to treat chronic tonsillitits can lead to peritonsillar abscess formation.

Adenoiditis

Inflammation of the pharyngeal tonsils. This is usually bacterial, although it may be viral or due to allergies. Recurrent adenoiditis can lead to hypertrophy. Hypertrophic tissue can cause snoring due to nasal obstruction or hearing impairment due to Eustachian tube blockage. The palatine tonsils and adenoids are often removed in a combination procedure called a tonsillectomy and adenoidectomy (T&A)

Peritonsillar abscess

Peritonsillar abscess formation is a major complication of tonsillitis, resulting from a failed antibiotic therapy or chronic tonsillitis. Patient is in extreme pain and may experience difficulty breathing and referred pain in the ear on the affected side.

Sleep apnea

(not breathing) numerous, brief interruptions in respiration during sleep, leaving the patient feeling sleepy during the day. Life threatening, can lead to irregular heart beats, high blood pressure, heart attack, and stroke. Pharmacologic treatment, bariatric surgery, septoplasty or T&A are some surgeries that may help.

Laryngitis

Inflammation of the vocal cords. Vocal cord nodules generally result from vocal abuse. The only symptom is prolonged hoarseness. The nodules do not increase in size, nor are they considered precancerous. There is no danger or airway obstruction.

Laryngeal neoplasm

May be benign or malignant. Evidence may included changes in voice quality and pain. May arise from any structure within the larynx and is not limited to vocal cords. Laryngectomy, radical neck dissection, radiation therapy.

Tracheitis

Bronchitis, may be acute (virus) or chronic (irritants).

Esophagitis

Inflammation of the esophagus, caused by reflux of stomach acids. Can lead to the formation of a stricture, may require surgery.

Zenker's diverticulum

An out-pouching of the wall of in the esophagus. The patient usually complains of dysphagia, or difficulty swallowing. Can be seen on X-ray with contrast or endoscopically.

Bronchoscopy

To remove a foreign body, obtain diagnosis, or treat a condition. For flexible, the patient is often given a topical anesthetic, for rigid, general is the treatment of choice.

Laryngoscopy

To examine the larynx and can be direct or indirect. Also accomplished the same way as bronchoscopy.

Esophagoscopy

Diagnostic or for removal of a foreign body.

Adenoidectomy

Removal of pharyngeal tonsils that have become enlarged. Done under general anesthesia, patient in supine, with neck hyper-extended by a roll placed under the shoulders. An adult patient may receive a local anesthetic and will be placed in the sitting position.

Tonsillectomy

Removal of the palatine or faucial tonsils.

Paratidectomy

Excision of a portion or all of the parotid gland. Common disorder is the formation of stones that block Steno's duct. Very important to identify the facial nerve during paratidectomy. Have facial nerve identifiers ready for surgeon.

Uvulopalatopharyngoplasty (UPPP)

Treatment for intractable snoring and obstructive sleep apnea. Redundant tissue of the fauces, the tonsils (if present), and a portion of the soft palate including the uvula are removed. Removal of adenoids, if necessary. Surgeon uses a #12 curved knife blade.

Radical neck dissection

Unilaterally. Removal of the cervical lymph nodes, jugular vein, and sternocleidomastoid muscle (SCM). While performed alone to treat metastatic squamous cell carcinoma, also done in conjunction with mandibulectomy for metastatic lesions of the mouth and jaw. The use of viable composite grafts, immediately follow RND, fibula, and adjoining vessels, commonly used. An approach employing 2 surgical teams working concurrently is recommended.

Thyroidectomy

Thyroidectomy is the surgical removal of the thyroid gland. This important gland, located in the lower front portion of the neck, produces thyroid hormone, which regulates the body's production of energy.

Parathyroidectomy

Parathyroidectomy is surgery to remove parathyroid glands or parathyroid tumors. The parathyroid glands are right behind your thyroid gland in your neck. These glands help your body use calcium.

Panendoscopy

Refers to a procedure that may involve inspection of several portions of the upper aerodigestive tract.

Vocal cord polyps

Polypoid corditis can result from chronic laryngitis. The patient complains of chronic hoarseness but exhibits no other symptoms.

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