INSTRUMENTS IN ENT

DEPARTMENT OF ENT & HEAD-NECK SURGERY

NSCB MEDICAL COLLEGE JABALPUR
 • NASAL SPECULUM

• USES
a. Diagnostic: Anterior
rhinoscopy — nasal
septum, Little’s area,
lateral wall of nose,
nasal cavity
• Held over the hooked index finger of
the non-dominant hand with blades b. Therapeutic: removal
directed inwards.The blades are then of foreign bodies,
closed by pressing between middle and antral wash, nasal
ring finger. packing, surgical
procedures inside the
nose.
 Uses:
a. Diagnostic: Anterior
rhinoscopy—nasal
septum, Little’s area,
lateral wall of nose,
nasal cavity.

b. Therapeutic: Removal of
foreign bodies, antral
This is a self-retaining nasal wash, nasal packing,
speculum and is available with surgical procedures
blades of different sizes. The inside the nose like
distance between the blades polypectomy, SMR,
can be adjusted and fixed septoplasty, etc
with a screw.
 USES
For examination of -

tongue base,
valleculae,
glosso-epiglottic fold,
pharyngo-epiglottic fold,
arytenoids,
ary-epiglottic folds,
ventricular bands,
vocal cords,
inter-arytenoid region,
This instrument has a handle, shaft pyriform fossae and
and a plain mirror at an angle. The posterior pharyngeal wall.
focal length of this mirror is at infinity. These regions can be examined for any
The mirror is available in various sizes foreign body, inflammatory, noninflammatory,
ranging from 8 m m to 30 mm. traumatic or neoplastic lesions.

The tongue is held with a dry gauze piece with the left hand. The handle of the mirror is held
like a pen The patient is asked to breathe through the mouth. The patient is asked to phonate
‘eee’ for observing vocal cord adduction and is asked to breathe gently for observing vocal
cord abduction.
 USES

• Posterior rhinoscopy
• to examine the postnasal
space after adenoidectomy
• to look for remnants if any.

This instrument has a bayonet shaped T h e m i r r o r surface is

handle (hence differs f r o m indirect either heated or dipped in
laryngoscopy mirror) so that the examiner’s savlon (or touched against
hand does not block his vision. The mirror oral mucosa) in order to
is available in sizes of 0 to 5 and should be prevent fogging during
of an appropriate size so as to pass behind the procedure. The tongue
soft palate and reflect sufficient light for the is depressed gently with a
image to be seen. This is a plain mirror and tongue depressor and this
does not magnify the image. mirror is introduced inside
like a pen with the mirror
facing upwards.
STRUCTURES NOT SEEN IN THIS PROCEDURE:

• Post-cricoid region
• Apex of pyriform fossa

• Ventricles

• Undersurface of vocal cords and adjoining sub glottic region

• Laryngeal surface of epiglottis.

PITFALLS OF INDIRECT LARYNGOSCOPIC EXAMINATION:

• There is anterior & posterior reversal of structures in the mirror image

• Overhanging of epiglottis may obscure vision
• The anterior commissure is poorly visualised
• Depth perception is poor
• The procedure is difficult in children
• The tongue may rise on phonation and may obscure the view of larynx
• The procedure is difficult in a person with short neck
• The vocal cords appear short and flat in the mirror
 USES
1. Intranasal antrostomy -for
the drainage of chronic
maxillary sinusitis

2. As an adjunct procedure
during Caldwell-Luc surgery.

It is an instrument used to make an opening in the medial wall of the

maxillary antrum. The puncture is made just below the genu of the inferior
turbinate where the bone is thinnest. It is held like a dagger in one hand
and the index and thumb of the other hand are used for an adequate
fulcrum.It has one antegrade pointing tip and three retrograde pointing
tips.While the instrument is removed, a piece of bone could come out
thereby enlarging the antrostome.
USES-
This instrument is
used to smoothen
the margins of
the intranasal
antrostoma.
 USES-
It is used to enlarge the
antrostomy opening
Created by antral
harpoon

This instrument has an ante grade and retrograde cutting edge.

 USES -
a. Antral wash

b. Nasal douching
in atrophic
rhinitis.

It has a bulb with red rubber tubing on either side. One end of the rubber tubing
ends in a valve and the other ends in a nozzle.The valve allows only inflow of
water into the bulb.The valve end is kept in water and the nozzle end is
connected to the antral wash cannula.The capacity of the bulb is about 50 ml
and the syringe is made up of red rubber material.
 USES -

• Diagnostic proof
puncture: to obtain
aspirate of the
maxillary sinus for
analysis.
• To drain pus in
maxillary sinusitis.
• Instillation of medicine
Parts — handle with long pointed end, cannula into maxillary antrum.
with connecting end for irrigation.
Procedure of antral puncture: The antral puncture is done in the inferior meatus
1cm behind the anterior end of inferior turbinate.The trocar & cannula is directed
towards the outer canthus of ipsilateral eye. The trocar is now withdrawn from the
cannula. The valve end of the Higginson syringe is dipped in the warm water.The
bulb is squeezed and the sinus is irrigated with water after connecting the syringe
to the cannula.The patient is advised to breathe through the mouth.
USES-

It is used to nibble bone

spicules and fragments
during

-maxillectomy,
-lateral rhinotomy &
-Caldwell-Luc operation.
This is a knife that can rotate 360 degrees within its two prongs.Hence, it can
be positioned without rotating the instrument and the direction can be
changed. This instrument is used in sub mucous resection of septum and also
to harvest cartilage for rhinoplasty & tympanoplasty.
 USES -

a. Remove hard bone

during mastoidectomy
A gouge is an instrument with a curved rounded tip
that has smooth bevelling. Hence, it cuts bone in a b. Caldwell-Luc
operation
circular pattern. It is held at an acute angle to the
bone for cutting it and a mallet is used for hitting c. Excision of exostosis
in external auditory
on it. The gouge has been replaced by the
canal.
electrical drill in the present day.
This instrument appears like a hammer and is used along with a gouge, chisel
or osteotome. The gouge is to be hit by a mallet with movement at the wrist
during septal surgery.
Used to curette chunks of bone from mastoid and ear canal during ear
surgeries like tympanoplasty, mastoid exploration or stapedotomy.Can also be
used to remove granulation tissue and cholesteatoma.
 AURAL SPECULUMS

• Holmgren
Tumarkin aural
adjustable
speculum:
aural This
speculum:
aural speculum
This is ahas
self-retaining
a complete split
adjustable
on
aural
its body
speculum
to facilitate
with aintra-aural
screw. Used injections
for examination
into the of
external
ear and
canal.
ear surgeries.

HARTMANN SHEA ROSEN

• Hartmann
Rosen auralaural
Shea aural speculum:
speculum:
speculum ThisThis
: This anisaural
isaural aspeculum
funnel shaped
speculum withspeculum
resembles that has
Hartmann
an incomplete no
aural
slit on
slit on
its theHowever,
speculum.
body. body.
The slitThe broader
isthe narrow
useful end
for end isofthickened for external
this speculum
injections on the better grip.
is beveled.
canal wall with the
speculum in place.

HOLMGREN SELF RETAINING TUMARKIN

USES -
Examination of-
• external ear canal &
• tympanic membrane
Removal of -
• wax,
• foreign body,
• otomycosis or
• ear discharge.
In operative procedures like-
• myringotomy,
• myringoplasty,
• stapedotomy,
• stapedectomy
For transcanal injections.
 The tuning fork is struck at the
junction of upper one-third and
lower two-third of the prongs.
The vibrating tuning fork with the
prongs in the acoustic axis is
placed at a distance of 2.5 cm
from the auricle for air conduction.
HARTMANN The vibrating tuning fork is then
placed with the base touching the
mastoid process for bone
conduction.It is available in various
frequencies—
128, 256, 512 & 1024.
The 512 Hz tuning fork is commonly
GARDINER USES - used for the following reasons.

PARTS: • It is present in the mid speech

• To detect the type of frequency range
• Two prongs hearing loss • Overtones are minimal
• Shoulder • To make an approximate • Sound is more auditory than
• Stem estimate of the degree of tactile in nature
• Base hearing loss. • Tone decay is optimal.
 USES:

1. Harvesting
temporalis fascia
2. Mastoidectomy,
tympanoplasty
3. In head and neck
surgeries like
tracheostomy &
laryngofissure.

This is a self-retaining mastoid retractor with four prongs on either blade.

Besides retracting the tissue and fascia from the field of operation it can also
secure haemostasis by compressing the vessels.
 USES

• Glossectomy

• Soft palate and floor of the

mouth surgery

• Tongue tie release

• Dental surgery.

• Excision of ranula, benign

tumors, cysts and calculus

It is a self-retaining mouth gag used to • In unconscious patients to

open the mouth by anchoring on the teeth open the mouth and
prevent airway obstruction

• Caldwell Luc operation.

 It has two components:Boyle
blade and Davis gag that are
used simultaneously. It helps
to keep the mouth open and
push the tongue up and
away from the operation
site.Upper tooth plate has
small holes to which a rubber
tube is sutured to prevent
trauma to the incisor
tooth.The mouth gag is
introduced in the closed
position after opening the
mouth with the head
extended.The mouth gag is
gradually opened and the
Indications: ratchet lock makes it self-
a. Tonsillectomy retaining.The whole assembly
b. Adenoidectomy can be lifted up and
c. Surgeries of palate and nasopharynx maintained in that position
d. Excision of choanal polyp. using Draffin bipods.
It consists of two rods with multiple rings in a row.Used to anchor
and fix the Boyle Davis mouth gag for numerous oropharyngeal
surgeries including adeno-tonsillectomy.
This instrument is used to curette the adenoids by a blind technique.The
curette is introduced behind the soft palate with the blade facing down.It
is held like a dagger & the adenoid is curetted from the nasopharyngeal
wall in the midline by sweeping movement.The cage is used to prevent
slipping of the excised tissue into the throat. During the procedure, the
neck of the patient should not be in too much extension as it might
injure the atlanto-occipital joint.
Another variety without cage is called Beckman adenoid curette.
It has a blunt end used for initial non-traumatic dissection of the
tonsil. The retracting end is used to retract the anterior pillar to
look for bleeding points and tags of tonsillar tissue left behind.
The snare has a stainless steel wire which is usually 3 inches long with a
thickness of 28 gauge.It is used to snare the lower pole of the tonsil after
dissection.The lower pole is crushed on snaring & thromboplastin is
released which is a powerful vasoconstrictor.

(CUTTING AND CRUSHING ACTION)

This is used to catch bleeding points in the tonsillar fossa after
tonsillectomy.It is replaced by Negus second artery forceps
underneath the first artery forceps before ligation.

TRANSVERSE SERRATIONS
It has a curved tip and is used after the first artery forceps for
ligating blood vessels in a deep site.
It is used in tonsillectomy. The single tooth of the forceps is used
to incise the anterior pillar. It can also be used for the dissection
of tonsil from its bed and also as a swab holder. There is a stud
in one of the arms that can be felt through a vent in the opposite
arm. This is useful to note the pressure exerted at the tip.
Serrations only at the tip of the blades.It can also be used in the nose.

USES:
a. For packing or unpacking the ear canal or mastoid cavity
b. For delivery of medicated dressings into the ear canal
c. For packing and unpacking the nose
d. For introduction of medicated pledgets for local anesthesia
in the nasal cavity
e. Removal of foreign body/crusts/debris in the nose and ear.
 This instrument resembles
Luc forceps but differs from
it in the following:

• The edges of the jaw

are blunt and do not
cut tissue.

• The upper jaw is

smaller than the
lower jaw.

• The tip has a box

mechanism.

It is used to hold the tonsil and pull it medially during the process of dissection.
 Uses -
• SMR or septoplasty for
removal of cartilage and
bone
• Polypectomy
• Caldwell-Luc operation
• Edge biopsy from
oralcavity & oropharynx
• Turbinectomy.

This forceps has a screw

joint & has a fenestrated tip
with sharp blades that
grasp the tissue and cut it.
Hence, this forceps is
suitable for biopsy of
various soft tissues and
delicate bone.
 USES -
• Examination of oral cavity
and oropharynx
• To retract lips and cheek
• To express pus out of the
tonsil— septic squeeze test
• To test gag reflex
• For cold spatula test to
check patency of nasal
passage
• For posterior rhinoscopy
• For oral cavity procedures
like injection of steroids,
biopsy, excision of cysts,
etc.

It has a flat end and a slightly curved end.The flat end is placed over the anterior
two-third of the tongue to depress it.The posterior one-third should not be
touched in order to prevent gag reflex.
It is bayonet shaped instrument with a sharp trocar tip.It has a guard at some
distance from tip to prevent deep entry.For draining quinsy sharp tip is pierced with
the forceps closed.The instrument is then opened like a sinus forceps to drain the
abscess.
This is a hollow rigid tube with a beveled end.The adult bronchoscope is about 40 to
45 cm long.It has vents on the side for ventilation of the other bronchus when they
remain above the level of carina when inserted into the major bronchus & hence
differs from esophagoscope.
USES:

Diagnostic:
• For examination of tracheo-bronchial tree for
pathology - growth, ulcer, stricture, etc.
• Biopsy from a suspicious growth or ulcer
• Bronchial lavage from secretions
• Bronchography
• Autofluorescence

Therapeutic:
• Foreign body removal
• Tracheobronchial stenting
• Aspiration of secretions
• Removal of tumors.
It is a long rigid hollow tube of 40 to 45 cm length and 16 to20 mm diameter. It is
available as Negus and Jackson type. The Negus type generally has double proximal
illumination, tapers distally and has markings on it. The Jackson type has single distal
illumination and has no markings and does not taper distally.In distal illumination, the
light can get fogged due to its proximity to the distal end.

Parts:

• Handle
• Eyepiece (Proximal
end)
• Body or shaft
• Light carrier
• Distal opening.
USES:

Diagnostic
• Malignancy
• Foreign body examination
• Cardiospasm
• Tracheoesophageal fistula
• Stricture.

Therapeutic
• Removal of foreign body
• To guide bougies through esophageal
strictures
• Esophageal stenting
• Sclerosing agent injection
• into esophageal varices.
This is a ‘U’ shaped instrument made up of German silver. It uses a rigid fiberoptic
light carrier for illumination.The position of the structures is not changed unlike
indirect laryngoscopy & there is no magnification. Based on the type of illumination
there are two types : Jackson and Negus.
USES:

• For examination of larynx,

hypopharynx, cricopharynx
& upper esophagus
• Removal of foreign
bodies from the above
regions
• For biopsy from tumors
• For excision of tumors or
nodules from the glottis or
supraglottis
• To assess the extent of
laryngeal growth before
laryngectomy.
It is an instrument
used to dilate the
tracheostoma
during or after the
tracheostomy to
insert the
tracheostomy tube.
It allows easier
introduction of the
tracheostomy tube
and prevents
formation of a false
passage.
 Parts:
a. Biflanged outer tube:collar present to tie ropes
b. Inner tube:has two circular rings to grasp, remove and insert the tube.

This is a metallic tracheostomy tube and has an inner tube that is longer than the
biflanged outer tube. This prevents the outer tube from getting blocked by
secretions. The inner tube can easily be removed for cleaning. Also the posterior
wall of the inner tube has an opening that permits the patient to breathe through
the nose and phonate. The two flanges of the outer tube can be compressed for
initial introduction into the trachea. Hence a pilot is not necessary for introduction.
The compressed flanges of the outer tube hold the inner tube in place and prevent
it from getting coughed out. Hence a lock system is not required in this tube.
Parts:
• Inner tube
• Outer tube: Contains a
collar & a locking
mechanism
• Pilot obturator

Disadvantages:
• Phonation is not possible
• The patency of the
natural air passage
cannot be checked by
blocking the tube
• There is a risk of
granulation tissue
formation.

There is a pilot for

introducing the tube
into the trachea so that
injury is not caused to
the posterior wall
Advantages of portex tubes:
•Made up of soft material, hence less damaging to the
tracheal wall
•Since it has a cuff it is particularly useful for intensive care
unit patients
•It is useful during radiotherapy
•It has a blue radiopaque line all along the tube for radiological
detection of the site of the tube.

Disadvantages of portex tubes:

•Cleaning the tube is more difficult—requires removal
•Phonation not possible usually
•Checking the patency of natural air passage is not possible
•Cuff might injure the tracheal wall (tracheal necrosis) if
overinflated and left for a longer period of time
(Pressure should be preferably less than 30 m m of Hg)
T HA N K U