MODULE 20 Otorhinolaryngology Surgery RPN2023.pdf

MODULE 20: Otorhinolaryngology Surgery Suggested Readings Alexander’s Care of the Patient in Surgery (2022) Chapter 19 Tighe (2015) Instrumentation for the Operating Room Chapter...

MODULE 20: Otorhinolaryngology Surgery Suggested Readings Alexander’s Care of the Patient in Surgery (2022) Chapter 19 Tighe (2015) Instrumentation for the Operating Room Chapter 68, 69, 70, 73, 75, 76 ORNAC Standards 2023 Learning Outcomes Describe the anatomy of the ears, nose, throat Explain relevant surgical interventions and procedural considerations for ENT procedures. Otorhinolaryngology is the study and science of the human ear (oto), nose (rhino), and throat (laryngo). Anatomy Ear - A sensory organ that recognizes, locates, and interprets sounds. The ear also maintains equilibrium. The external ear, middle ear, and inner ear are the three anatomic segments of the ear that work together to provide hearing and balance. External ear includes the auricle and external auditory canal, which are made up of cartilage and skin. Incoming sound waves are conducted into the external auditory canal. The canal lining is protected and lubricated by a waxy substance called cerumen. It traps foreign material and reduces bacterial levels in the ear. Middle Ear – Begins at the end of the auditory canal or tympanic membrane, also known as the ear drum. The middle ear is filled with air that flows from the pharynx through the Eustachian tube. The posterior aspect of the middle ear communicates with the mastoid air cells of the temporal bone. The middle ear’s mucous membrane continuous with the pharynx and mastoid cells, which makes it possible for infection to travel to the middle ear and mastoid cells. A chain of three small articulating bones, called the ossicles (malleus, incus, and stapes), stretch across the middle ear cavity. Their moveable joints amplify the received sound, which is transmitted and converted from ambient air in the middle ear to the fluid in the inner ear. Inner ear - A curved membranous cavity located in the petrous segment of the temporal bone, containing hair cell receptors that provide us with hearing and balance. The inner ear consists of a labrynth filled with watery fluid. This bony labyrinth consists of the cochlea and vestibular labrynth. The cochlea looks like the shape of a snail shell. The basilar membrane of the cochlea has hair cells that convert mechanical energy of the vibrations into electrochemical impulses. The vestibular labrynth is made up of the Module 20: ENT  utricle, saccule, and three semicircular canals. They detect angular acceleration elicited from head and body movements. The canals trigger impulses in the vestibular branch of the acoustic nerve (8th cranial nerve). Test your knowledge by identifying the structures below: Nose - The most prominent feature of the face, therefore, is easily exposed to trauma. Skin covers the surface of the nose, which is supported by cartilage and bone. There are two external nares that are the air passage openings to the nasal cavity. The purpose of the nose is to humidify and filter the air before entry into the lungs. The tip of the nose and nostrils are shaped by alar cartilages. The columella separates the nares. The nasal cavity is divided into right and left portions by the nasal septum. The nasal septum is made up of three structures; nasal cartilage, perpendicular plate of the ethmoid bones, and vomer bone. The rich blood supply of the septum moistens and warms the air. While the sticky mucous traps small particles, such as dust. The nasal sinuses communicate with the sinuses via the meatus. The sinuses include frontal sinus, ethmoid sinus, sphenoid sinus, and maxillary sinus. Module 20: ENT Throat - Consists of the oral cavity, pharynx, larynx, and its associated structures. The oral cavity consists of the mouth and salivary glands. The cheeks, hard palate, tongue, and mandible forms the mouth. The mouth also extends to the soft palate, teeth, and lips. Sublingual glands, submandibular glands, and parotid glands make up the salivary glands of the oral cavity. The pharynx serves as the digestive and respiratory passageway that extends from the nose to the larynx and esophagus. The pharynx communicates with several cavities, which include the esophagus, mouth, nasal cavities, tympanic cavities, and the larynx. The cartilaginous box that serves as the passageway into the respiratory system is called the larynx. The larynx has a valve (epiglottis) that prevents aspiration. The vocal cords (supraglottis, glottis, subglottis) are also situated in this cartilaginous box. The trachea is anterior of the esophagus, beginning at the neck and divides into the right and left bronchi. This airway structure is composed of a series of c-shaped rings of cartilage. The sternohyoid muscles, sternothyroid muscle, and the thyroid glands lay posteriorly from the trachea. Module 20: ENT  Perioperative Nursing Considerations Nursing Assessment The patient’s respiratory status is assessed pre-operatively, including the patient’s character, quality of breathing, and smoking history and/or exposure to secondhand smoke. The patient’s nutritional status is assessed, such as weight loss related to difficulty swallowing/chewing. Assess the facial structures for symmetry, landmarks, colour, position, lesions, and nodules. Assess the patient’s pain levels. Patient’s requiring resection and reconstructive surgery of the face or neck, have implications on the patients’ body image. The patients may experience long-term hearing loss, facial numbness, difficulty swallowing, or aesthetic changes as a result from surgery. Anaesthesia Considerations- Patients may receive local anaesthetic with neurolept for some procedures, such as tracheostomy or middle ear surgeries lasting less than two hours. If the patient is having local anaesthetic with neurolept, ensure all instructions have been reviewed with the patient. Remind the patient to remain immobile intraoperatively. Provide reassurance to the patient during the surgery, when needed. Ensure that the environmental noise is kept to a minimum. Signs indicating that the patient is awake may be placed outside the OR doors as a reminder to OR staff. Indicated patients may receive general anaesthetic due to their health condition or surgical requirements. Module 20: ENT For rhinologic surgeries, the nasal cavity is packed with patties soaked with the vasoconstrictor solution. The surgeons may inject the local anaesthetic with epinephrine before or after prepping the nasal cavity. In laryngeal surgery, lidocaine may be applied topically to the larynx to prevent the patient from coughing. Topical epinephrine may also be applied directly to the larynx to achieve vasoconstriction, especially when there is bleeding after a biopsy. Prep -The surgical sites in head and neck surgeries may require hair removal before prepping. Hair removal is performed only if it interferes with the access to surgical field or if the hair risks falling into the wound. If indicated, clippers are used, instead of razors. Ensure that the hair is clipped as close to the time of the surgery in a room where the procedure will not take place. Providone-iodine solution is a commonly used prep solution in otorhinolaryngology, unless the patient has an allergy. It has been shown to be safe for use in the middle ear, using the swabbing application method. Chlorhexidine is avoided because it is ototoxic. Patient Positioning - The surgical procedure determines the patient’s intraoperative position. Patients who are undergoing head and necks surgeries are commonly in supine position with a shoulder roll placed posteriorly (between the patient’s scapula for maximum visualization). Refer to the ORNAC Standards and the positioning performance checklist for appropriate practices. The patient position and the associated positioning devices may vary depending on the surgeon’s preferences and available institutional resources and policies. It is recommended that the perioperative nurse collaborates with the surgical team to ensure that the patient is positioned safely before, during, and after surgery. The perioperative nurse ensures that the patient return electrode pad is applied and the safety strap secured. Instrumentation and Counting Otorhinolaryngology requires procedure specific instruments, including short and fine instruments that require delicate handling. Otologic surgery Myringotomy knife with disposable spear or lancet shaped blades Aural speculum with ear curettes Middle ear instruments, such as ear speculums Rhinosurgery Throat pack Sinuscope Module 20: ENT  A light source with a camera monitor to maximize visualization. Boies elevator or asch forceps to elevate and mold the nasal bones Alar retractor Skin hooks Stevens scissors Freer elevator Oral Cavity / Laryngologic/ Neck Surgeries Telescope, light cord, biopsy forceps, suction tip, teeth guard, and 4x4 sponges may be needed. Molts Retractor to open mouth Tonsil forceps to grasp tonsils Cautery and tonsil guillotine clamps Minor instrument set: mosquitoes, hemostats, louers, reynaulds scissors, metz scissors, mayo straight scissors, debakey or cooley forceps, Jefferson forceps, toothed adson forceps, self-retaining or handheld rakes, langenbeck retractor, skin hooks, dura hooks, hemoclip appliers Silk ties, hemoclips, vessel loops Sterile nerve stimulator to protect the recurrent laryngeal nerves. Power drills with burrs and bits needed if bones are resected. Tracheal dilator Tracheostomy cannula with obturator Most head and neck surgeries require a minor count. Initial Count (minor) → Closing Count (minor) → Final Count (minor) Equipment The OR needs to be prepared with monopolar and bipolar cautery, suction, light sources, monitors, camera systems, and headlights. Microscope – Used to provide illumination and magnification for complex procedures to the ear, laryngeal surgery, or reconstructive free flap procedures following neck surgery. Several kinds of surgical microscopes with different attachments are available. The microscope requires a specific microscope drape during surgery to prevent contamination of the surgical field. When the microscope is not in use, ensure that it is stored in an upright position in a low- traffic area. Power Drills – Used with assorted burrs and bits for middle ear surgery and some sinus procedures. Drills may be powered pneumatically or electronically, and should be used in conjunction with sterile water upon activation. Sharp safety principles are applied when using Module 20: ENT power drills. Ensure that the power drills are placed in the safe mode during its exchange between surgeon and scrub nurse. Ensure that the drill/burr is securely fastened and tested safety before use. Laser (CO2, KTP, Er:YAG, and Nd:YAG) - Assist in the vaporization of scar tissue, granulomas, and cholesteatomas without damaging surrounding tissue. Forced-Air Warming Blankets – Used to prevent hypothermia, unless contraindicated. There must be a continuous assessment of patient’s temperatures to ensure normothermia intraoperatively. Surgical Interventions Otologic Surgeries The majority of otologic procedures are performed either through the ear canal (endaural or transcanal) or from behind the ear (postauricular). Myringotomy – Incision into the pars tensa of the ear drum or tympanic membrane Myringotomy tube is inserted and left in place. Tubes fall out on their own when the ear drum heals. Antibiotic drops instilled postoperatively Mastoidectomy - Removal of mastoid air cells, most frequently to treat cholesteatoma. There are three types: simple mastoidectomy, modified mastoidectomy, and radical mastoidectomy. There are two approaches, endaural or postauricular approaches. There is a high risk for facial nerve injury, therefore, facial nerve monitoring is needed. If stapedectomy is completed, a stapes prosthesis is needed. External auditory canal is packed postoperatively with antibiotic ointment. Tympanoplasty – Repair of the tympanic membrane and reconstruction of the ossicles. This surgery is indicated for patients with conductive hearing loss or perforation of the tympanic membrane. A graft may be taken from the ear lobe, back of the ear, or tragus for repair External auditory canal is packed postoperatively with antibiotic ointment. Operative ear is covered with gauze dressing. Cochlear Implantation– Implantation of an assistive hearing device into the cochlea for patients with sensory hearing loss. An electrode and an implant is inserted and attached to an external sound processor. The external sound processor sits above the skin behind the ear. Auditory training and psychologic counseling commonly needed after surgery for candidates. Module 20: ENT Rhinologic Surgeries Functional Endoscopic Sinus Surgery (FESS) - A surgical treatment involving the insertion of an endoscope through the nasal cavity and into the sinuses for the purpose of resecting inflammatory and anatomic defects of the sinuses. The purpose of FESS is to ensure adequate drainage of the sinuses by resecting tissue and creating increased aeration of the sinuses. OR lights are turned off. Local infiltration may be used ie. Lidocaine with epinephrine Topical epinephrine on patties may be used in the nasal cavity to achieve better visualization and vasoconstriction of the sinuses before prepping the surgical incision, as well as intraoperatively. The patient’s nose will most likely be packed postoperatively with a moustache dressing. After surgery remind the patient to breathe through mouth because her/his nose will be packed. Closed Reduction of Nasal Fracture– Manual realignment or correction of a nasal fracture without the creation of a skin incision. Local infiltration may be used ie. Lidocaine with epinephrine Topical epinephrine on patties may be used in the nasal cavity to achieve better visualization and vasoconstriction of the sinuses before prepping the surgical incision, as well as intraoperatively. The patient may have nasal packing or Denver splint inserted into the nasal cavity to stabilize the reduction. Postoperative mustache dressing may be used. After surgery remind the patient to breathe through mouth because her/his nose will be packed. Module 20: ENT  Nasoseptoplasty – Straightening of the cartilaginous or osseous segments of the septum between the mucous membrane and the perichondrium. Septal deviations may block the meatus and compress turbinates, compromising air entry. The objective of the procedure is to establish an adequate partition between the left and the right nasal cavities, thereby providing a clear airway through both internal and external cavities of the nose. The nasal cavity is highly vascularized, therefore, there can be excessive bleeding intraoperatively. Local infiltration with epinephrine used to aid in hemostasis. Topical epinephrine on patties is applied to nasal cavity intraoperatively for hemostasis. Plastic or Silastic splints may be inserted with the purpose of preventing adhesions and hematoma. Splints are removed several weeks after surgery. Postoperative mustache dressing may be applied. Oral Cavity / Laryngologic/ Neck Surgeries Laryngoscopy – To visualize the glottis or vocal cords using a rigid, lighted speculum called a laryngoscope. A suspension laryngoscopy may be indicated, using self-retaining laryngoscope holder. This laryngoscope holder allows the surgeon to suspend the laryngoscope above the patient’s head, mounted on the OR table or a Mayo Stand to free up the surgeon’s hands during surgery. The scrub team commonly wear only sterile gloves. No sterile surgical gowns are required. Specimens or secretions may be sent for pathologic examination. May use patties soaked with topical epinephrine to stop bleeding after tissue biopsy. Tonsillectomy – Excision of the tonsils. Adenoidectomy and tonsillectomy may be done concurrently. Module 20: ENT Thyroidectomy - Removal of the thyroid gland. Thyroidectomies may involve unilateral thyroid lobectomy, subtotal lobectomy, bilateral subtotal thyroidectomy, near-total thyroidectomy, or total thyroidectomy. Lymph nodes may be excised if there is a known or suspected thyroid cancer. If the patient has a large goiter, it is recommended to complete a major count, in the event that the chest cavity is entered. Risk of injury to the recurrent laryngeal nerves intraoperatively. Drains are inserted in the neck incision before skin closure. If the goiter is extremely large that it invades the patient’s chest, a sternotomy may be performed for successful removal. Be attentive to the patient during anaesthesia emergence. If the patient coughs, it may cause a hematoma in the surgical site. If this occurs, the surgical site needs to be re- opened. Parotidectomy - Removal of one or more parotid glands. Risk of injury to the facial nerve. Drains are inserted in the surgical incision before skin closure Be attentive to the patient during anaesthesia emergence. If the patient coughs, it may cause a hematoma in the surgical site. If this occurs, the surgical site needs to be re-opened. Radical Neck Dissection - Removal of malignant head and neck tissues, such as cervical nodes, fascia, jugular vein, 11th cranial nerve, sternocleidomastoid muscle, mandible, maxilla, thyroid, or parotid. The patient may require reconstructive surgery that involves harvesting tissue and bone from the patient’s own body. In a modified neck dissection, the sternocleidomastoid muscle, internal jugular vein, and 11th cranial nerve are preserved. Airway access may be problematic; therefore, the patient may need a tracheostomy performed before the proposed neck dissection. The surgical site varies depending on the procedure. Some neck dissections require reconstructive surgery with free flaps from the radial arm, fibula, anterolateral thigh, or scapula. The face and neck along with the harvest site for the free flap needs to be prepped and draped. A plastics surgical team may be involved for the reconstruction with the free flap. The patients may experience facial numbness, difficulty swallowing, or aesthetic changes as a result from surgery. Tracheostomy - Opening of the trachea and insertion of a cannula through the cricoid cartilage. Performed as an elective or emergency procedure. The tracheostomy cannula size and type must be confirmed with the surgeon before the trachea is opened. The introducer or obturator is attached to the patient’s chart. Module 20: ENT