Tracheostomy & Otolaryngology PDF

TRACHEOSTOMY & OTOLARYNGIOLOGY- ` TRACHEOSTOMY This procedure relieves airway obstruction or protects the airway By fashioning a direct entrance into the trachea through the skin of the neck. Tracheostomy may be carried out as an emergency for acute airway obstruction. The best time to...

TRACHEOSTOMY & OTOLARYNGIOLOGY- ` TRACHEOSTOMY This procedure relieves airway obstruction or protects the airway By fashioning a direct entrance into the trachea through the skin of the neck. Tracheostomy may be carried out as an emergency for acute airway obstruction. The best time to do a tracheostomy is when you first think it may be necessary. 1- Emergency tracheostomy If a skilled anesthetist is unavailable, local anaesthesia is employed, but when the patient is unconscious, none is required. The operation is more difficult in small children and thick-necked adults as the landmarks are difficult to palpate. the patient should be laid supine with padding placed under the shoulders and the extended neck kept as steady as possible in the midline. A vertical midline incision is made from the inferior aspect of the thyroid cartilage to the suprasternal notch and A tracheostomy tube is inserted into the trachea Position of the skin incision in an emergency tracheostomy. An incision in the trachea in an emergency  2- Elective tracheostomy The advantage of an elective surgical procedure is that there is complete airway control at all times, unhurried dissection and careful placement of an appropriate tube. Close cooperation Between the surgeon, anesthetist and scrub nurse is essential, and attention to detail will markedly reduce possible complications and morbidity from the procedure. Following induction of general anesthesia and endotracheal intubation, the patient is positioned with a combination of head extension and placement of an appropriate sandbag under the shoulder , A transverse incision may be used in the elective situation Position of the patient for elective tracheostomy elective tracheostomy.  3-Percutaneous tracheostomy As an alternative to open tracheostomy, a percutaneous tracheostomy is commonly performed in the critical care setting. A transverse skin incision is made at the level of the first and second tracheal rings A 22-gauge needle is inserted between the second and third tracheal rings Tracheostomy tubes Most modern tracheostomy tubes are made of plastic. Tubes of various sizes with varying curves, angles, cuffs, inner tubes and speaking valves are available. After a newly fashioned tracheostomy is created, a cuffed tube is used initially to protect the airway from secretions or bleeding , This may be changed after 3–4 days to a non-cuffed tube.  Modern plastic tracheostomy tube with introducer, low-pressure cuff and inner cannula. All forms of tracheostomy bypass the upper airway and have the following advantages: the anatomical dead space is reduced by approximately 50%; the work of breathing is reduced; alveolar ventilation is increased; unlike endotracheal intubation, the patient may be able to talk and eat with a tube in place. However, there are several disadvantages: loss of heat and moisture exchange in the upper respiratory tract; the presence of a foreign body in the trachea stimulates mucous production; where no cilia are present, the mucociliary stream is therefore impeded; the increased mucus is more viscid and thick crusts may form and block the tube; although many patients with a tracheostomy can feed satisfactorily, there is some splinting of the larynx, which may prevent normal swallowing and lead to aspiration; Ear , nose, and sinuses Disorders affecting the ear, nose and sinus are common reasons for primary care attendance; however, few surgeons will encounter such diseases in day to day practice. THE EAR 1-The external ear The external ear canal is 3 cm in length outer two-thirds is cartilage and the inner third is bony. 2- The tympanic membrane and middle ear The tympanic membrane and ossicles act as a transformer of vibrations in the air to vibrations within the fluid-filled inner ear. 3- The inner ear The inner ear comprises the cochlea and vestibular labyrinth CONDITIONS OF THE EXTERNAL EAR A hematoma of the pinna occurs when blood collects under the perichondrium. A generous incision under anesthetic, with a pressure dressing and antibiotic cover, is recommended. Foreign bodies in the ear canal are most easily removed at the first attempt by an experienced practitioner with the aid of a microscope. General anaesthesia may be required in children and those with learning difficulties. The correct method of holding the otoscope. Note the pinna is retracted to straighten the ear canal Haematoma of the pinna Inflammation and infection Otitis externa The term otitis externa usually refers to a diffuse process that involves the entire external auditory canal. It is also known as “swimmer’s ear” because moisture remaining in the external canal after swimming or showering may lead to this infection. Trauma to the delicate skin of the canal or exposure to purulent middle ear discharge through a perforation may initiate otitis externa. clinically range from minimal inflammation and tenderness to complete closure of the ear canal, with surrounding cellulitis and adenopathy. Management involves removing debris from the external auditory canal, so that topical antibiotic ear solutions may reach the site of the infection. If the ear canal is so swollen that ear drops cannot be instilled, a small wick is placed into the external auditory canal. If there is a marked cellulitis or inflammation involving the auricle and the tissues around the ear, systemic antibiotics and steroids CONDITIONS OF THE MIDDLE EAR 1-Trauma Trauma to the middle ear can result in a perforated tympanic membrane 90% of such perforations heal spontaneously with 6 weeks. Perforations may develop from previous otitis media. Those that do not heal spontaneously are usually large. If healing is not evidenced within several months, a tympanoplasty using a temporalis fascia graft is indicated to close the perforation. 2- Acute otitis media Acute otitis media (AOM) occurs in 70% of children by the age of 2 and 90% by the age of 6. It is characterized by purulent fluid in the middle ear. The child suffers extreme pain until the tympanic membrane bursts. Treatment is with analgesics and antipyretics. Systemic antibiotics should be reserved for children under 2 with bilateral disease or those with other risk factors for complications THE NOSE AND SINUSES TRAUMA TO THE NOSE AND PARANASAL SINUSES Blunt injury to the nose may fracture the nasal bones ,The fracture line can extend into the lacrimal bone and tear the anterior Ethmoidal artery, producing catastrophic hemorrhage. Violent trauma to the frontal area of the nose can result in a fracture of the frontal and ethmoid sinuses with potential extension into the anterior cranial fossa. Fractured nasal bones are normally accompanied by extensive overlying soft-tissue swelling and bruising, which may hinder the assessment of any underlying bony deformity. Reviewing after 4–5 days when the soft-tissue swelling has diminished will allow a better assessment of any deformity this can be corrected by manipulation of the nasal bones under local or general anaesthesia. This should be carried out within 3 weeks of the injury while the bony fragments are still mobile. EPISTAXIS Anterior bleeding is common in children and young adults as a result of nose blowing or picking. In the elderly, anticoagulants and hypertension are the underlying causes of arterial bleeding from the posterior part of the nose. Management of epistaxis 1- Anterior bleeding from anterior part may be controlled by silver nitrate cautery under local anesthesia. 2- posterior epistaxis, the bleeding point can often be identified using rigid nasendoscopy and controlled with the use of a topical vasoconstrictor, and then dealt with directly using electrocautery. Fracture of the nasal bones with displacement of the bony nasal complex to the right side. 3- posterior bleeding, as seen in the elderly, may require anterior nasal packing either with Vaseline-impregnated ribbon gauze or a non-absorbable sponge. 4- An alternative to anterior packing is the use of an inflatable epistaxis balloon catheter Postnasal packing may be required in refractory cases whereby a gauze pack is positioned in the nasopharynx under general anaesthesia. Acute tonsillitis This common condition is characterized by a sore throat, fever, general malaise, dysphagia, enlarged upper cervical nodes and sometimes referred otalgia. Approximately half the cases are bacterial, The remainder are viral. On examination, the tonsils are swollen and erythematous, yellow or white pustules may be seen on the tonsils, Treatment Paracetamol or similar analgesia may be administered to relieve pain and gargles ; and systemic antibiotic. Quinsy This is an abscess in the peritonsillar region that causes severe pain and trismus. Inspection reveals a diffuse swelling of the soft palate just superior or lateral to the involved tonsil, displacing the uvula medially, pus may be seen pointing underneath the thin mucosa. Treatment In the early stages, intravenous broad-spectrum antibiotics if there is frank abscess formation, incision and drainage Of the pus can Be carried out under local anaesthesia. Tonsillectomy Recurrent acute tonsillitis is the most common relative indication for tonsillectomy in children and adolescents, Absolute indications for tonsillectomy are when the size of the tonsils is contributing to airway obstruction or a malignancy of the tonsils is suspected DISEASES OF THE LARYNX Stridor Stridor means noisy breathing. It may be inspiratory or expiratory, mor occur in both phases of respiration.