INSTRUMENTS

in
ENT
DR Veeresh D
Dept of ENT
KIMS Koppal
 It consists of a plastic
headband to which is attached
adjustable concave mirror
with a central hole.
The diameter of the mirror is
9 cm while that of the central
aperture is 2 cm and the
focal length of the mirror is
approximately 18 cm.

when parallel rays of light from the Bull’s lamp impinge on the concave
mirror, the light rays converge at the focal point of the mirror. The
advantage of wearing this head mirror is that 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.

2
ENT HEAD MIRROR
ENT HEADLIGHT
ENT HEADLIGHT
This consists of a metal box
with vents within which is kept
a
100 W bulb. The light rays
come out through a central
opening.

This opening has a biconvex

lens
of appoximately
30 to 40 cm focal length. The
lamp is placed 30 cm behind
the left ear of the patient. The
lamp can be adjusted to focus
the rays on the head mirror.

6
It is a hand-held battery
operated instrument used to
visualize the external auditory
canal, tympanic membrane and
the middle ear through the
tympanic perforation. It has a
convex lens which gives a
magnification of two times. It
has a fiberoptic light
conveyance system for delivery
of light to the aural speculum
that is available in different
sizes. Some of the otoscopes
have a provision
for attachment of
pneumatic speculum for
Seigelization.

Pneumatic attachment
Used for checking the
mobility of the TM. Can also
be used for fistula test.
JOBSON HORNE PROBE WITH RING CURETTE

It has two ends. One end has a serrated probe and the other end
has a ring.
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
 TILLEYS NASAL PACKING FORCEPS

Serrations only at the tip of the blades. It can also be used in the
Ear
Uses:
a. For packing and unpacking the nose
b. For introduction of medicated pledgets for local anesthesia
in the nasal cavity
c. Removal of foreign body/crusts/debris in the nose and ear.
d. For packing or unpacking the ear canal or mastoid cavity
e. For delivery of medicated dressings into the ear canal

9
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.
The following are its uses:
[Link] of oral cavity
and oropharynx
b. To retract lips and cheek
[Link] express pus out of the tonsil—
septic squeeze test
d. To test gag reflex
[Link] cold spatula test to
check patency of nasal
passage
f. For posterior rhinoscopy
[Link] oral cavity procedures like
injection of steroids, biopsy,
excision of cysts, etc.
10
 It is a metallic catheter with
a curved proximal end and
a ring at its base. The
opening of its curved
proximal end is at its tip.
This instrument is usually
12 toon
Ring 15the
cm proximal
long. end
indicates the direction of
the tip of the catheter.
Other tests of Eustachian
tube
Uses: dysfunction:
a. To test the patency of Eustachian tube a. Valsalva maneuver
b. To inflate the middle ear b. Siegelization
c. To instill medications in the middle ear c. Politzerization
d. To remove foreign bodies from the d. Toynbee maneuver
nose e. Frenzel maneuver
e. As a suction cannula. f. Sonotubometry
g. Impedence audiometry
[Link] evaluation—X-
ray, salphingography, CT 2
6
 • self-retaining nasal speculum

• USES:

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

3
THUDICUMS NASAL SPECULUM
 Uses
: Examination of the external ear canal and tympanic membrane
Removal of wax, foreign body, otomycosis or ear discharge
In operative procedures like myringotomy,
myringoplasty, stapedotomy, stapedectomy
For transcanal injections.

There are several types of aural speculum.

[Link] adjustable aural speculum This is a self-retaining adjustable
aural speculum with a screw. Used for examination of ear and ear surgeries.
b. Hartmann aural speculum: This is a funnel shaped speculum that has no
slit
on the body. The broader end is thickened for better grip.
[Link] aural speculum 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.
d. Shea aural speculum: This aural speculum resembles Hartmann aural
speculum. However, the narrow end of this speculum is beveled.
[Link] aural speculum: This aural speculum has a complete split on
its body to facilitate intra-aural injections into the external canal.

Compiled by: Sauradeep Dey ( deysauradeep@[Link])

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24
The mirror surface is either heated or This instrument has a
dipped in savlon (or touched against oral bayonet shaped handle
mucosa) in order to prevent fogging (hence differs from indirect
during the procedure. The tongue is laryngoscopy mirror) so that
depressed gently with a tongue the examiner’s hand does
depressor and this mirror is introduced not block his vision. The
inside like a pen with the mirror facing mirror is available in sizes of
upwards. 0 to 5 and should be of an
USES appropriate size so as to
• Posterior rhinoscopy pass behind soft palate and
•to examine the postnasal space after reflect sufficient light for the
adenoidectomy to look for remnants if image to be seen. This is a
any. plain mirror and does not
Posterior
Rhinoscopic
Examination
 USES
[Link] examination of larynx for
any foreign body, inflammatory,
This instrument has a handle, shaft noninflammatory, traumatic or
and a plain mirror at an angle. The neoplastic lesions.
focal length of this mirror is at [Link] remove small foreign bodies like
infinity. The mirror is available in fish bone.
various sizes ranging from 8 mm to [Link] remove tissue for
30 mm. histopathological
examination.
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.
6
Indirect Laryngeal Examination
Indirect
Laryngeal
Examination
Structures not seen in this
Post-cricoid :
procedure region
Apex of pyriform fossa
Ventricles
Undersurface of vocal cords and adjoining subglottic region
Laryngeal surface of epiglottis.
Pitfalls of indirect laryngoscopic examination:
There is anterior and posterior reversal of structures in the mirror
image

Overhanging of epiglottis may obscure vision

The anterior commissure is poorly visualized

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

The vocal cords appear white due to the reflection of a greater amount of
 Procedure of antral
puncture: The antral
puncture is done in the
inferior meatus 1 cm
behind the anterior end of
inferior turbinate. The
trocar and cannula is
directed towards the outer
canthus of ipsilateral eye.
Parts—handle with long pointed end, cannula The trocar is now
with connecting end for irrigation. withdrawn from the
cannula. The valve end of
USES
the Higginson syringe is
[Link] proof puncture: to obtain aspirate
dipped in the warm water.
of the maxillary sinus for analysis.
The bulb is squeezed and
b. To drain pus in maxillary sinusitis.
the sinus is irrigated with
c. Instillation of medicine into maxillary
water after connecting the
antrum.
syringe to the cannula. The
d. Oro-antral fistula.
patient is advised to
breathe through the
mouth. 25
 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
USES antral wash cannula.
The capacity of the
a. Antral wash bulb is about 50 ml
b. Nasal douching in atrophic and the syringe is
rhinitis. made up of red rubber
material.

26
 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. 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 and 1024. The 512 Hz
GARDINER Tuning Fork tuning fork is commonly used
for the following reasons.
PARTS: USES [Link] is present in the mid
• Two prongs [Link] detect the type of speech frequency range
• Shoulder hearing loss b. Overtones are minimal
• Stem [Link] make an approximate [Link] is more auditory
• Base estimate of the degree of than tactile in nature
hearing loss. d. Tone decay is optimal.

TYPES Hartmann TF, Gardiner 25

HARTMANN Tuning Fork
It is used to nibble bone spicules and fragments during
maxillectomy, lateral rhinotomy and Caldwell-Luc
operation.

29
It is used to remove spicules of bone in surgeries like
Caldwell-
Luc operation, Lynch-Howarth operation, maxillectomy, etc.
30
 Uses
:
a. Diagnostic: Anterior
rhinoscopy—nasal
septum, Little’s area,
lateral wall of nose, nasal
cavity.

This is a self-retaining nasal b. Therapeutic: Removal

speculum and is available with of foreign bodies, antral
blades of different sizes. The wash, nasal packing,
distance between the blades can be surgical procedures inside
adjusted and fixed with a screw. the nose like
polypectomy, SMR,
septoplasty, etc

4
32
 Uses:
This instrument is bent obtusely [Link] or total
at the centre and has narrow
blades with blunt tip and turbinectomy
works in the vertical plane. [Link] be used to cut the
cartilage in septal surgeries.

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USE
[Link] elevate mucoperichondrial
a
and periosteal flap in septal
surgeries
[Link] displacement of inferior
turbinate in antrostomy
operation
[Link] elevating canal skin and
cartilage perichondrium in
mastoid surgeries
[Link] elevation of mucosa in
Caldwell-Luc operation
e. To spread and tease
temporalis fascia graft
f. To perform uncinectomy. 18
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 submucous
resection of septum and
also to harvest cartilage
for rhinoplasty and
tympanoplasty.
19
A gouge is an instrument with a curved rounded tip that has smooth
beveling. Hence, it cuts bone in a circular pattern. It is held at an acute
angle to the bone for cutting it and a mallet is used for hitting on it. The
gouge has been replaced by the electrical drill in the present day.
USES
a. Remove hard bone during mastoidectomy
b. Caldwell-Luc operation
c. Excision of exostosis in external auditory canal.

20
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.

21
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.

22
This instrument is used to
remove wax and foreign
bodies from the ear. One
end of this instrument has a
ring vectis while the other
end has a blunt curette.

27
It is an instrument used to make an incision on the tympanic membrane
for serous otitis media or unresolved acute otitis media. The incision
may be in the anteroinferior quadrant for serous otitis media or
posteroinferior quadrant for acute otitis media. The incision is radial for
serous otitis media and circumferential for acute otitis media.
Ventilation tube may be inserted on this incision if required in serous
otitis media.
41
It is a metallic syringe with a
nostle piston inside a
cylindrical body and a handle.

Uses:
a. To remove softened wax
[Link] remove non-hygroscopic
foreign body and small
hygroscopic
foreign bodies.

Contraindications:
c. Perforated tympanic
membrane
d. Otitis externa
e. CSF otorrhea
f. Large hygroscopic foreign
body
[Link] or thinned out
tympanic membrane.

43
 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 hemostasis
by compressing the
vessels.

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

44
This is a micro ear instrument used mainly to make a horizontal incision on
the external canal wall skin during elevation of tympanomeatal flap.

It is also used to elevate tympanomeatal flap. Hence used in middle

ear surgeries like myringoplasty, tympanoplasty and ossiculoplasty.

46
 Uses
: External canal skin
a.
tympanomeatal incision

b. Elevation of tympanomeatal flap

during myringoplasty,
Tympanoplasty
[Link] the margins and
undersurface of the
perforation during
myringoplasty and
tympanoplasty
It is a micro-ear instrument that has a
sharp spade like rounded tip. The [Link] break middle ear adhesions,
upper surface of the spaded tip might especially between handle of
be serrated for roughening the malleus and promontory as in a
undersurface of the remnant case of atelectasis
tympanic membrane. This spaded tip
might also have small vents to [Link] clear granulation tissue and
permit suction. The tip is bent at an cholesteaoma in certain hidden
angle of 120° to the shaft. areas of the middle ear like
facial recess and sinus 35
 Uses:
[Link] hold graft materials
like temporalis fascia
and transfer it from one
place to another

[Link] hold and transfer gel

foam and cotton pledgets

[Link] hold and transfer

ossicles, teflon piston,
grommet or
TORP/PORP
This instrument is available as straight (A),
downturned (B) or upturned (C) forceps. [Link] upturned and
known as crocodile
Also downturned types are used
forceps. to reach crevices and
If tip has cups, teeth or scissors then inaccessible areas in the
they are known as Wullstein middle ear and mastoid for
cupped/toothed alligator forceps and the above purposes.
micro-ear scissors respectively.
[Link] removal, oral 3
6
 USES

[Link]

b. Soft palate and floor of

the
mouth surgery

c. Tongue tie release

d. Dental surgery.

[Link] of ranula, benign

tumors, cysts and calculus
It is a self-retaining mouth gag used
to open the mouth by anchoring on
[Link] unconscious patients to
the teeth
open the mouth and
prevent airway obstruction

g. Caldwell Luc operation.

49
This is a self-retaining mouth gag similar to Doyen mouth
gag. However, the mechanism by which this gag remains
open is different.
Use = same as Doyen mouth gag

50
 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
Indications: opened and the ratchet lock
a. Tonsillectomy makes it self- retaining. The
b. Adenoidectomy whole assembly can be lifted
c. Surgeries of palate and up and maintained in that
nasopharynx position using Draffin bipods.
d. Excision of choanal polyp.

51
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
adenotonsillectomy.

52
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.

Another variety without cage is called Beckman adenoid curette.

This instrument is also used to hold the (upper pole of) tonsil to pull it
medially prior to dissection. It is especially useful where the tonsil is
friable and the grip cannot be changed repeatedly.

42
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.

56
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 and thromboplastin is released which is
a powerful vasoconstrictor.
(CUTTING AND CRUSHING ACTION)

57
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.

59
It is used to push the ligature loop on the Negus second
artery
forceps to ligate the bleeding point.

60
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.

61
It is a long bent instrument with a
stout handle. The tip of the tube
has a rounded blunt cap with
small holes. This prevents trauma
to the dissection field. The bent
tube enables the surgeon to
visualize the dissection field
better. The multiple openings in
the tip of suction tube will
facilitate suction even if the main
opening is blocked.

This instrument is used for all oral

and oropharyngeal surgeries
including adenotonsillectomy
besides maxillectomy,
laryngectomy and other neck
surgeries.

62
It has two blades and a long handle with finger grip and a
ratchet. The ratio of length of handle to blade is 4:1. The blade
has criss- cross serrations (or groove) on the inner aspect to
grip the needle.

63
It is a forceps resembling artery forceps but has no ratchet.
The inner surfaces of the blades are serrated and the tip is
blunt. It is mainly used for draining an abscess by breaking
the loculi inside after making an incision.

65
It is used to hold the
tonsil and pull it
medially during the
process
of dissection.

This instrument
resembles Luc forceps
but differs
from it in the following:
[Link] edges of the jaw
are blunt and do not
cut tissue.
[Link] upper jaw is
smaller than the
lower jaw.
[Link] tip has a box
mechanism.

66
This forceps has a screw
joint and 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
: .SMR or septoplasty for
a
removal of cartilage
and bone
[Link] and
Caldwell-Luc
operation
c. Edge biopsy from
oral
cavity and oropharynx
d. Turbinectomy.

67
 Parts
: Grip rings
a.
b. Stalk
c. Fenestrated blades

Uses:
[Link] pass endotracheal
tube
[Link] difficult cases of
Ryle’s tube insertion
[Link] remove foreign body
from pharynx
g. For throat packing.

This is an angulated forceps

commonly used to orient
and guide the endotracheal
***DOES NOT LIE IN A tube into the larynx. This
PLANE angulation is done in order
to prevent the obstruction
to the view of the surgeon.
68
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.

69
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 Uses:
the other bronchus when they remain above the Diagnostic
level of carina when inserted into the major :
bronchus and hence differs from [Link] examination of
esophagoscope. tracheobronchial tree for
pathology—growth,
ulcer, stricture, etc.
[Link] from a
suspicious growth or
ulcer
[Link] lavage from
secretions
d. Bronchography
e. Autofluorescence
and
photodynamic
diagnosis.

Therapeutic:
f. Foreign body
removal
[Link]
stenting
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
In distal
taper illumination, the light can get fogged due to its proximity to the
distally.
end
distal Uses:
. Diagnostic
a. Malignancy
b. Foreign body
examination
c. Cardiospasm
d. Tracheoesophageal
fistula
e. Stricture.

Therapeutic
Parts:
f. Removal of foreign body
a. Handle
[Link] guide bougies through
[Link] (Proximal
esophageal strictures
end)
h. Esophageal stenting
c. Body or shaft
i. Sclerosing agent
d. Light carrier
injection
e. Distal opening.
into esophageal varices.
62
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:
a. Biflanged outer tube: collar present to tie ropes
b. Inner tube: has two circular rings to grasp, remove and insert the
tube.
Disadvantages:
[Link] tip of the flanges can
injure the tracheal wall
[Link] can break after long
use and present as foreign
bodies
[Link] is a risk of granulation
tissue formation.
Parts:
a. Inner tube
[Link] tube: Contains a collar
and a locking mechanism
c. Pilot obturator
Disadvantages:
d. Phonation is not possible
[Link] patency of the natural
air passage cannot be
checked
by blocking the tube
c. There is a risk of granulation
tissue formation.
There is a pilot for introducing
the tube into the trachea so that
injury
The Frenchis gauge
not caused to isthe
(FG or FR)
posterior wall
three times the outer diameter
(millimeters) of the tube. This
FG system is commonly
followed for identifying the
number of metal tracheostomy 6
6
Portex Cuffed Tracheostomy Tube
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 mm of Hg.

Compiled by: Sauradeep Dey ( 79

deysauradeep@[Link] )
71