ENT INSTRUMENTS BY MBBS GANG
Nose related Instruments
[Link] Nasal Speculum
How to hold?
Step 1: Use non dominant hand and hold the instrument at its bend with your thumb and index finger.
Step 2: Place your middle and ring fingers either side of the limbs of the speculum.
Step 3: Bringing these fingers close to each other will also bring the flanges of the speculum
close together. Insert the instrument into the nostril in this position. Moving your
middle and ring fingers apart will widen the flanges of the speculum, opening up the Nasal cavity in this
process.
(Note: Always close the flanges while retracting from Nasal vestibule)
Description - It is a self-retaining Nasal Speculum.
Uses:
a. Diagnostic: Anterior rhinoscopy—nasal septum, Little’s area, lateral wall of nose, nasal cavity
b. Therapeutic: Removal of foreign bodies, antral wash, nasal packing, surgical procedures inside the
nose
[Structures seen on anterior rhinoscopy]
2. St. Clair Thomson's Nasal Speculum
Description - (i) Self retaining nasal speculum.
(ii) Longer blades- helps in [a] Deeper visualization, [b] Different from Thudicum Nasal
Speculum which has shorter blades, [c] Useful in nasal surgeries (e.g., Keeping two separated flaps
apart in SMR, to avoid injuries to the flap and septal perforation)
Uses:
a. Septoplasty/SMR
b. Polypectomy
c. Deep foreign bodies removal.
3. Nasal Foreign Body Hook
Uses: Nasal foreign body removal, commonly in children.
Note: Commonest history for nasal foreign body obstruction is history of unilateral foul-smelling nasal
discharge and nasal obstruction
N
-
M-0
4. St. Clair Thompson Posterior Rhinoscopy Mirror ~o
ID: Bayonet shaped handle (different from indirect laryngoscopy mirror which has straight handle)
Uses: Used in out-patient procedures for posterior rhinoscopy.
Usage: The mirror surface is either heated or dipped in Savlon in order to prevent fogging during the
procedure. The tongue is depressed gently with a tongue depressor and this mirror is introduced inside
like a pen with the mirror facing upwards. The patient is asked to breathe through the nose. The mirror
is now introduced behind the soft palate without touching the posterior pharyngeal wall to reflect the
light towards the nasopharynx.
5. Tilley's Nasal Dressing Forceps
ID: (a) Bent at an angle to prevent obstruction in examiner's view.
(b) Blades are long, thin, and SERRATED, STRAIGHT (unlike triangular tips of aural forceps )
Uses: (i) Anterior nasal packing. (ii) Remove foreign bodies, crusts or packs from the nose. (iii) Pack the
nose with gauze strips during nasal surgeries or sinus surgeries. (iv) Remove cartilage and bone pieces
during septoplasty or SMR.
NOTE: Tilley's nasal forceps has box type joint.
-
Hartman's nasal forceps has screw type joint and the Jaw are serrated and grooved.
6. Killian Short and Long Blade Nasal Speculum:
It is a self-retaining nasal speculum and is available with blades of different sizes. The distance can be
adjusted and fixing it with screw.
Uses:
a. Diagnostic: Anterior rhinoscopy—nasal septum, Little’s area, lateral wall of nose, nasal cavity
b. Therapeutic: Removal of foreign bodies, antral wash, nasal packing, surgical procedures inside the
nose like polypectomy, SMR, septoplasty, etc.
7. Luc's forceps:
Uses:
1. To remove bone, cartilage and soft tissues in various nasal operations: eg. SMR, Antrostomy, Caldwell
Luc operation. 2. In nasal polypectomy. 3. To take punch biopsies from oropharyngeal cavity and
nasopharynx.
8. Lichtwitz Antrum Puncture Trocar And Cannula: Not important)
Use: Mainly it is used for antral puncture washout (APW) Antrum is punctured through inferior meatus,
(most dependent and most accessible area for drainage) ,usually under local anaesthesia, as it is the
Diagnostic 1. To confirm presence of pus in the maxillary sinus and diagnosis of
chronic sinusitis (Proof puncture method).
2. Cytological examination of antral wash out fluid.
Therapeutic 1. For lavaging the maxillary sinus in chronic sinusitis and oroantral fistula.
2. Introduction of indwelling polythene tube in chronic sinusitis in children.
3. Introduction of medication in the antrum.
9. Asch forceps
The forceps tip has a gap in between the blades even in closed position to prevent the crushing of
structures (I.e., nasal septum) hold by the forceps. Looks like "A".
"A" for Asch forceps. ("A" like appearance)
Use: Lifting the septum upward during reduction of fractures of nasal bone.
10. Walsham forceps
ID: (1) It is straight forceps unlike Asch's forceps
(2) Rubber tube covering over one blade to prevent any skin injury over external nose.
Use: Disimpacting the fracture in the reduction of fracture of nasal bones.
11. Tilley’s Harpoon And Antral Burr Not important)
TILLEY’S ANTRAL
HARPOON
Uses:
Tilley’s harpoon: to puncture the medial wall of the antrum at the inferior meatus in
antrostomy operation in case of chronic sinusitis/ along with Caldwell Luc operation.
Tilley’s antral burr: It is used to dilate and smoothen the antrostomy opening following puncture by the
harpoon.
Ear Instruments
[Link] Fork
Commonly used tuning fork has a frequency of 512 Hz. Forks of other frequencies, e.g., 256 and 1024 Hz
should also be available
[Link]-Horne ear probe with ring curette
ID:
> One end of the probe is ring shaped. This end may be used to hook out wax or foreign bodies
from the ear canal.
`
-> The other end of the instrument is sharp and serrated. An ear wick can be fashioned out of this end
by rolling cotton on to it and used to mop ear discharge.
Uses:
a. Removal of wax
b. Removal of foreign body in the ear and nose
c. Removal of granulations in the ear
d. The probe end is used to probe polyp in the nose and ear
e. The probe end can act as a cotton swab carrier and can clean the ear or apply medication
14. Ear vectis with cerumen spud
ID - One end of this instrument has a ring vectis while the other end has a blunt curette
Uses: to remove wax and foreign bodies from the ear.
15. Aural Forceps
more curved
↓
Tapered
end
recurved
15a) Hartmann Aural forceps:
ID: Different from Tilley's Aural forceps- as the tip is wide and spade like.
Use: hence, used to deliver dressings and medications into the ear. It can also be used to remove
foreign bodies in the ear canal.
15b) Tilley's Aural Forceps:
ID: Angled instrument with 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 anaesthesia in the nasal cavity
e. Removal of foreign body/crusts/debris in the nose and ear.
16. Sympson’s Aural Syringe
Parts of the instrument
1. Nozzle,
2. Cylinder,
3. Plunger.
Uses of the instrument
1. Removal of foreign body and wax.
2. Removal of otomycotic plug.
3. Aural toilet.
Technique of syringing the ear
>Patient is seated with ear to be syringed towards the
examiner.
> A towel is placed round his neck.
> A kidney tray is placed over the shoulder and held snugly by the patient.
> Patient's head is slightly tilted over the tray to collect the return fluid.
> Pinna is pulled upwards and backwards and a stream of water from the ear syringe is directed along
the posterosuperior wall of the meatus.
> Pressure of water, built up deeper to the wax, expels the wax out.
>If wax is tightly impacted, it is necessary to create a space between it and the meatal
wall for the jet of water to pass, otherwise syringing will be ineffective or may even push the wax
deeper.
> Ear canal should be inspected from time to time to see if all wax has been removed. Unnecessary
syringing should be avoided.
> At the end of the procedure, ear canal and tympanic membrane must be inspected and dried with a
pledget of cotton.
Note:
-Any ulceration seen in meatal wall as a result of impacted wax is protected by
application of suitable antibiotic ointment.
-Normally, boiled tap water cooled to body temperature is used. If it is too cold or too
hot it would stimulate the labyrinth, as in caloric testing, and cause vertigo.
-Too much force used in syringing may rupture the tympanic membrane especially
when it has already been weakened by previous disease. Patient complains of intense
pain and may become giddy and even faint.
-It is necessary before syringing to ask the patient for any past history of ear discharge
or an existing perforation. A quiescent otitis media may be reactivated by syringing
Contraindications:
a. Tympanic membrane perforation (including a patent myringotomy tube),
b. Monomeric or dimeric tympanic membrane (a thin, weak area of the membrane where one or two
layers have healed after perforation),
c. The presence of vegetable matter such as a bean or a pea,
d. The presence of a watch or hearing aid battery,
e. Evidence of purulent exudate filling the canal, or a
f. History of ear surgery.
Complications:
a. Tympanic membrane rupture
b. Vasovagal attack
c. Injury to the external auditory canal
d. Vertigo due to stimulation of labyrinth.
17. Aural Speculum
Rosen aural speculum
N This is an aural speculum with an incomplete slit on its
body. The slit is useful for injections on the external canal
wall with the speculum in place.
Tumarkin aural speculum
This aural speculum has a complete split on its body to
facilitate intra-aural injections into the external canal.
Shea aural speculum
This aural speculum resembles Hartmann aural speculum.
However, the narrow end of this speculum is beveled.
Hartmann aural speculum This is a funnel shaped speculum that has no slit on the body. The broader
end is thickened for better grip.
Holmgren adjustable aural speculum
This is a self-retaining adjustable aural speculum with a
screw. Used for examination of ear and ear surgeries.
Uses:
Diagnostic: To examine the external auditory canal and tympanic
membrane.
Therapeutic: 1. Aural toileting is done through a speculum in case of CSOM.
2. Removal of foreign body/ wax etc.
3. Operative: Used in: Myringotomy, Myringoplasty, Stapedectomy.
↓ 4. Can be used as dilator in stenosis of external canal.
a
Hemostatic: separate periosteum
18. Mastoid retractor [sprong prongs
18a) Mollison's self-retaining mastoid retractor: 24X4)
Features: Used in mastoid surgery; self-retaining as it has lock to adjust; hemostatic as it has plates to
prevent bleeding by compressing soft tissue after incision.
18b) Jansen’s Self Retaining Mastoid Retractor- (3X3)
Uses:
>It is applied when skin, superficial fascia, muscle fibres and periosteum are incised for
retraction.
19. Farabeuf's Mastoid Periosteal Elevator
It has a thumb for gripping.
Uses: (1) elevates periosteum from mastoid cortex in mastoidectomy, tympanoplasty.
(2) Caldwell Luc's operation for elevating the periosteum.
20. Head Mirror
It is a concave mirror used to reflect light from the Bull's eye lamp onto the part being examined.
It has a focal length of approximately 25 cm.
The examiner sees through the hole in the centre of the mirror.
Diameter of the mirror is 89 mm (3½ ) and that of the central hole is 19 mm (3/4 ). It has a focal length
of 180mm.
Advantage: -It keeps both hands free for procedures. However, the head has to be kept fixed and
cannot be moved to any position like the headlight.
21. Ear dressing forceps
21a) Fagge Forceps 21b) Wide forceps
22. Lempert's Endaural Speculum
Use: Makes Endaural incision.
23. Lempert's Mastoidectomy Curette (not important)
Use: (1) Curette mastoid air cells.
(2) Opens the facial nerve if necessary.
24. MacEwen's Mastoid Curette and Cell Seeker
Use: (1) To curette the intervening septa in mastoidectomy.
(2) the cell seeker helps to identify aditus and explore the air cells.
Throat Instruments
25. Luc's Tongue Depressor
ID: It has two blades at right angles to each other. One limb is slightly wider and completely flat.
>This part of the tongue depressor is inserted into the oral cavity.
>The other blade is narrower and has a slight curve at its free end, like a handle. This is the part of the
instrument that is held in your hand.
Uses:
>Examination of the oral cavity – vestibule, buccal mucosa, gums, floor of the mouth.
>Examination of the oropharynx and posterior pharyngeal wall.
>Used in posterior rhinoscopy, along with the postnasal mirror.
>For the ‘cold spatula test’: to assess the nasal airway/ patency in the OPD.
>To perform minor procedures in the oral cavity.
> To take a throat swab or a swab from the tonsil.
How to use the tongue depressor:
Hold the instrument by the narrower blade that acts as a handle. Insert the other blade into the oral
cavity.
First retract the cheek so you can examine the vestibule, buccal mucosa and gums and
repeat the same on the other side.
Then place the blade flatly on the dorsum of the tongue and press it down – this will
allow you to examine the palate, tonsillar pillars, the tonsils and the posterior
pharyngeal wall.
Take care to depress only the anterior two-thirds of the tongue with this instrument.
Touching the posterior third of the tongue will elicit the gag reflex.
26. Laryngeal Mirror (Indirect Laryngoscopy)
Uses:
Diagnostic Use-indirect laryngoscopy.
Therapeutic use-
a. Removal of fish bone and other foreign body from base of the tongue,
vallecula, pyriform fossa etc.
b. For taking biopsy from the hypopharynx and larynx.
c. Local anaesthetic procedure of hypopharynx, larynx, trachea and bronchi.
d. For laryngography and bronchography.
e. Operative:
Removal of vocal cord nodule, papilloma of the larynx etc. is rarely performed by indirect laryngoscopy
due to modern endoscopy.
[How is indirect laryngoscopy performed?
Patient is seated opposite the examiner. He should sit erect with the head and chest leaning slightly
towards the examiner.
He is asked to protrude his tongue which is wrapped in gauze and held by the
examiner between the thumb and middle finger.
Index finger is used to keep the upper lip or moustache out of the way.
Gauze piece is used to get a firm grip of the tongue and to protect it against injury by the lower
incisors.
Laryngeal mirror (size 4 to 6) which has been warmed and tested on the back of
hand is introduced into the mouth and held firmly against the uvula and soft
palate.
Light is focussed on the laryngeal mirror and patient is asked to breathe quietly.
To see movements of the cords, patient is asked to take deep inspiration
(abduction of cords), say "Aa" (adduction of cords) and "Eee" (for adduction and
tension). Movements of both the cords are compared.
What are the structures are seen by indirect laryngoscopy?
Larynx. Epiglottis, aryepiglottic folds, arytenoids, cuneiform and corniculate cartilages, ventricular
bands, ventricles, true cords, anterior commissure, posterior commissure, subglottis and rings of
trachea.
Laryngopharynx: Both pyriform fossae, post-cricoid region, posterior wall of laryngopharynx.
Oropharynx: Base of tongue, lingual tonsils, valleculae, medial and lateral glosso-epiglottic folds.
Some types of laryngoscopy –
1. Direct laryngoscopy.
2. Indirect laryngoscopy.
3. Fibre-optic flexible laryngoscopy.
4. Prism-optically enhanced laryngoscopy.
5. Micro- laryngoscopy.
6. Video- laryngoscopy.
7. Stroboscopy
27. Direct Laryngoscopy
Procedure-
1. A piece of gauze is placed on the upper teeth to protect them against trauma.
2. Laryngoscope is lubricated with a little autoclaved liquid paraffin or jelly.
3. Laryngoscope is held by the handle in the left hand. Right hand is used, to retract the lips and guide
the laryngoscope and to handle suction and instruments.
4. Laryngoscope is introduced by one side of the tongue which is pushed to the opposite side till
posterior third of tongue is reached. It is then moved to the midline and lifted forward to bring the
epiglottis in view.
5. Laryngoscope is now advanced behind the epiglottis and lifted forward without levering it on the
upper teeth or jaw. This gives good view of the interior of the
larynx.
6. If anterior commissure laryngoscope is being used, its tip can be advanced further between the
ventricular bands to examine the ventricles and anterior commissure. It can be passed between the
vocal cords to examine the subglottic region.
7. Following structures are examined serially:
i) Base of tongue
ii) Right and left valleculae
iii) Epiglottis (its tip, lingual and laryngeal surfaces)
iv) Right and left pyriform sinuses
v) Aryepiglottic folds
vi) Arytenoids
vii) Post-cricoid region
viii) Both false cords, anterior and posterior commissure, right and left ventricles
ix) Right and left vocal cords and subglottic area.
x) Mobility of vocal cords should also be observed.
INSTRUMENTS NEEDED IN ADENOIDECTOMY SET:
1. Boyle Davis mouth gag with tongue blade
2. Doughty tongue blade/Russel Davis tongue blade
3. Draffin bipods
4. Magauren plate
5. St. Clair Thompson adenoid curette with cage
6. Beckmann adenoid curette without cage
7. Adenoid through cut forceps
8. Laforce adenotome (uncommonly used)
9. Adenoid tag forceps
10. Yankauer nasopharyngoscope (uncommonly used)
11. Yankauer pharyngeal suction tube
12. St. Clair Thompson postnasal mirror
INSTRUMENTS NEEDED IN TONSILLECTOMY SET:
Tonsillectomy Position
28. Boyle Davis mouth gag with tongue blade
It has two components: Boyle blade and Davis gag that are used simultaneously.
Uses: 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 ratchet lock makes it self-retaining. The whole assembly can
be lifted up and maintained in that position using Draffin’s bipods. The tongue depressor comes in
several sizes, from pediatric to adult.
Indications:
a. Tonsillectomy
b. Adenoidectomy
c. Surgeries of palate and nasopharynx
d. Excision of choanal polyp.
Precautions:
It cannot be used to perform procedures on the tongue as it is completely held down by the tongue
blade.
This instrument can cause injury to the lips and teeth. Care must be taken while
applying the mouth gag to avoid getting the lips caught in it.
Opening the mouth excessively with the gag can cause dislocation of the
temporomandibular joint.
29. Draffin’s bipod & Magauren Plate
Draffin’s bipod 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 adenotonsillectomy & Magauren plate is
used for supporting the Draffin’s bipods in place.
30. St. Clair Thompson adenoid curette with cage
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 and 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.
Endoscopic adenoidectomy achieves better results and lesser complications as the
procedure is performed under visualization.
Endoscopic adenoidectomy can be performed using endoscopic instruments and/or microdebrider.
31. Denis Browne’s Tonsil Holding Forceps
Uses: (1) To hold tonsil firmly and to pull inwards during tonsillectomy. This helps to stretch the anterior
pillar before incision and also to separate tonsil during operation.
It should be remembered that the tonsil holding forceps is to be held on the opposite hand of the
operating tonsil (i.e., if left tonsil is operated on, then tonsil holding forceps will be held on right hand
and tonsillar dissector is to be held on left hand)
This instrument resembles Luc forceps but differs from it in the following:
a. The edges of the jaw are blunt and do not cut tissue.
b. The upper jaw is smaller than the lower jaw.
c. The tip has a box mechanism.
32. Mollison Tonsillar Dissector and Pillar Retractor
serratedend
medially
blunt end
Laterally
It has a blunt end used for initial atraumatic 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.
33. Eve tonsillar snare not important
ID: The snare has a stainless-steel wire which is usually 3 inches long with a thickness of 28 gauge.
Uses: To snare the lower pole of the tonsil after dissection. The lower pole is crushed on snaring and
thromboplastin is released which is a powerful vasoconstrictor.
Instruments Use
Negus artery forceps (Replacement forceps) It replaces tonsil straight artery forceps
during ligation of bleeding after
tonsillectomy.
It is used to tie the ligature at a depth
and ligature will not slip out during
tying due to its curved tip.
Tonsil dissector and anterior pillar retractor The retractor end retracts the anterior
pillar after the tonsil is removed, to
inspect tonsillar fossa for any bleeding
points/remnant of tonsil.
The dissector end is used for dissection
of tonsils.
Negus knot Tier It helps to slip the ligature over the tip
of Negus artery forceps during ligation
of vessels in the tonsillar bed following
tonsillectomy.
TRACHEOSTOMY SET
[Link] Tube
34a. Chevalier Jackson metallic tube:
It has total 5 components -
The inner tube is longer than the outer tube. The inner tube removal helps to remove the blockening
secretions. lock prevents the inner tube from coming out during coughing, pilot helps for introduction
of the tube.
34b. Fuller Metallic Tube
This tube has hole on the top of inner tube which helps the patient to breathe through it and talk when
the tube is closed and this way it helps in early decannulation. This tube has compressible flanges so
easy to introduce without introducer.
Advantage: (1) Bypass the obstruction, (2) Reduces physiological dead space, (3) Bronchial toileting can
be performed. (4) The tube is made of German Silver that causes very less irritation to tracheal mucosa,
(5) Patients is able to speak due to opening in the outer tube
Disadvantage: Only disadvantage is that the patient cannot be connected to the ventilator when the
tube is used.
Opening on the postero-superior wall of the inner tube because it helps in decannulation, i.e.,
determines whether normal air passage is established on blocking the tracheostomy stroma.
35. Cuffed, Suction Aided Portex Tracheostomy Tube
It is a single tube, with no inner tube.
Advantage of the cuffed variety?
When the cuff is inflated, it prevents aspiration of pharyngeal secretions into the trachea. It is
used when there is danger of aspiration of pharyngeal secretions as in unconscious patients/
when patient is put on a respirator (Assisted ventilation).
Left-hand figure demonstrates the use of the BLUS subglottic suction port for the aspiration/removal of
material that collects above the cuff. The right-hand figure demonstrates the flow of gas if the suction
system is reversed and gas is delivered via the suction aid port to exit via the larynx, above the cuff. The
gas will escape through the upper airways and pass through the vocal cords, potentially allowing
vocalization. Ventilation of the lungs can continue independently. When the cuff is inflated, it prevents
aspiration of pharyngeal secretions into the trachea. It is used when there is danger of aspiration of
pharyngeal secretions as in unconscious patients/ when a patient is put on a respirator (Assisted
ventilation).
36. Tracheal dilator
It helps to introduce the tracheostomy tube by
dilating the opening.
37. Single Tracheal Hook Retractor not important)
It is used for retraction of isthmus of the thyroid/ soft tissues for exposure of tracheal wall in
mid/low tracheostomy operation.
38. Laryngeal forceps
It is used to remove the
laryngopharyngeal foreign body.
39. Gwynne Evan tonsillar dissector
ID: It has a blunt end and a serrated end.
Uses: Blunt end is used for the initial dissection of tonsil to obtain the proper plane. The serrated end is
used to cut the tissues from the upper pole, pillars and the tonsillar bed till the lower pole is reached.
