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CLINICAL APPLICATION OF ORL INSTRUMENTS
ADENOIDECTOMY
Boyle – Davis mouth gag (frame and tongue blade) used for exposure of the
oropharynx , oral cavity: for oropharyngeal and nasopharyngeal surgical procedures e.g.
adenoidectomy, tonsillectomy and Palatal surgery
Maguaran plate with bipod stand: Used for the suspension of Davis – Boyle mouth
gag during tonsillectomy, adenoidectomy, nasopharyngeal and palatal surgeries.
Maguaran plate
Draffin bipod. Advantage:- Easy to Sterilize, set up and assemble. No weight on the
patient. The position of the tongue blade can be altered intra-operatively if desirable.
Negus Jack stand and Guy suspension apparati are alternatives for support and
suspension of the Davis- Boyle mouth gag. Disadvantage is that it put weight on the
patient chest.
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NB: Eve’s Bipoid has a single ring unlike draffin with
four rings.
Draffin bipod
St. Clair Thompson adenoid currete
Distal end has a barbed or caged curette. Small plain curette can injure the
Eustachian tube.
St. Clair Thompson (1859 – 1943) was a reputable professor of laryngology.
In1878 entered Kings College London Medical Department. Qualified and appointed
House Surgeon to Joseph Lister, Professor of clinical surgery, Kings College, London,
1883. He became professor of laryngology in this hospital in 1905. Designed many
instruments including the adenoid curette and nasal speculum.
Uses:-
Used in curetting adenoid tissue during adenoidectomy and nasopharyngeal biopsy for
suspected nasopharyngeal tumor.
Doyen and Mason mouth gag can be use but the draw back is the lack of tongue
depressor which lifts the tongue and epiglottis to provide adequate operative field/space.
St. Clair Thompson adenoid curett Beckman adenoid curette
Yankauer suction nozzle. Have a proximal end for attachment to suctioning tube and a
distal end with a removable tip. Used for suctioning oral cavity and oropharynx during
surgical procedures.
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Yankauer suction nozzle
Electrocautery with a suction Bovie
This is a technique of using electrocautery with a suction Bovie to remove the adenoid
tissue or shrink the adenoids. The suction Bovie has a hollow center to suction blood or
secretions and a rim of metal contact for coagulation. This instrument can be set for pure
coagulation or for coagulation and cutting.
Surgical microdebrider: - Expensive and longer operation time.
Nd- yag laser:-Not cost effective over the traditional curetting method.
Adenoidotome:-This instrument is difficult to manipulate.
TONSILLECTOMY
Denis Brown tonsil holding forcep used for holding the tonsil during tonsillectomy.
Have a box joint; distal end has a ring with blunt, non lucking edges.
Denis Brown tonsil holding forceps
Volsellum and Turbinate luc forceps can also be used to hold tonsil for dissection but
they have sharp and lucking edges that easily tear tonsil tissue
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Gwynne Evans double ended tonsil dissector with one serrated end. Used for blunt
tonsillar dissection.
Wilson tonsil dissecting scissors have flattened blades and pointed ends. Used for
making mucosal incision before the blunt tonsillar dissection
Surgical blade can also be used for the mucosal incision down to the tonsillar capsule.
Wilson tonsil dissecting scissors
Eves tonsil snare used for avulsion of the tonsil at the tonsillolingual sulcus. It cuts and
avoids much blood loss, as too much dissection into the posterior faucial pillar and
lingual tonsil will result in rebound pharyngitis, fibrosis and retraction of the residual
pillar leading to velopharyngeal incompetence.
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Eves tonsillar snare Wilson tonsil artery forcep
Wilson tonsil artery forceps
Has a screw joint, curved on flat, angled shaft and serrated jaw
Uses:- for clamping of tonsillar artery during tonsillectomy to control troublesome
bleeding.
Yoakes tonsil compressing forceps with souper pad used for the control of troublesome
haemorrhage during tonsillectomy.
Yoakes tonsil compression Saymour Jones Adenoid tag forcep
forcep
Saymour Jones Adenoid tag forcep
It has proximal sliding and distal hinge joint. Stainless steel with silver colour finishing
Uses:-
Removal of adenoid remnant during adenoidectomy
Removal of tonsillar remnant
Maxillary antrum proof puncture & lavage
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Tilley Lichwitz antral trocar. Have metal handle, canula and tubing mount. It is used
for antral proof puncture for diagnostic procedure to elucidate X- RAY findings.
Assisting of acute and subacute antral infection. Higginson’s syringe is used for the
irrigation. 20ml syringe can be adapted for the Higginson’s syringe
Thudichum nasal speculum for anterior rhinoscopy
Thudicum nasal speculum
Intranasal antrostomy:- It was first suggested by John Hunter, carried out by Mikulicz
and Krause. Developed by Rethi and Claoue. Initial opening done with a Hill’s elevator
after raising a mucoperiosteal flap in the inferior meatus 2.5-3.5cm from the vestibule.
Mallet and Gouge are also used especially when the bone is dense. The opening is
enlarged with Luc’s forceps anteiorly. Posteriorly with Ostrom’s forward bitting forcep
Turbinectomy
. Luc nasal turbinate forceps used for nasal turbinate surgery. Clearance of nasal polyp
and antral mass.
Luc nasal turbinate forceps Killian nasal speculum
. Killian nasal speculum used for anterior rhinoscopy and hard fracture of the turbinate
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Fronto-Ethmoidectomy
Jansen – self retaining retractor with blunt blades used for retraction of muscle in
mastoidectomy and adapted in frontoethmoidectomy. Legenbeck retractor can also be
used. This will demand extra assistant(s)
Jansen self-retaining Mollison-self retaining retractor
Retractor
Mollisson self-retaining retractor used for temporal muscle retraction during
mastoidectomy and used also in frontoethmoidectomy
Hajek sphenoidal punch forcep. Has a handle, sliding joint. Two types, upward or
downward cutting. Used for enlarging the opening into the sphenoid sinus. Adapted for
removal of cortical bone during frontoeth moidectomy and widening the opening in the
floor of the frontal sinus.
Citelli and Lombards forcep can be adapted for widening the opening into the frontal
sinus.
Hajek sphenoidal punch forcep
SPHENOID SINUS PROCEDURES
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Hajek sphenoidal punch forcep. Has a handle, sliding joint. Two types upward or
downward cutting. Used for enlarging the opening into the sphenoid sinus. This was
applied intranasal after middle turbinectomy or hard fracture and ethmoidectomy.
Safe approach through external ethmoidectomy
Watson Williams rasp
It has a conical, flat forward cutting with metal handle used for enlarging frontal sinus
opening. Adapted for widening of antrostomy in maxillary antral surgery. . The actual
instruments for this are Myles naso-antral perforator and Tilleys antral bur,.
Watson Williams rasp
NASAL BONE FRACTURE
Walsham nasal redressing forcep used for closed reduction of fractured nasal bones.
The external bigger blade is covered with a piece of rubber tubing. The intranasal blade is
smaller
manouvre for procedure
[Link] movt
[Link] gentle pull
[Link] elevation
[Link]
Walsham nasal redressing forcep
Walsham septal straightening forcep used for closed reduction of septal dislocation or
subluxation. Asch’s septal forcep is used too for the reduction.
manouvre for procedure
[Link] elevation
[Link] movement
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[Link]
Walsham septal straightening forcep
INTRANASAL POLYPECTOMY
Tilly – Henckel punch forcep has calibrated upper surface and used for exenteration of
sphenoid sinus, nasal and antral biopsies.
Henckel punch forcep Citelli forcep
Citelli forcep used for clearance of nasal and sinus masses.
Luc nasal turbinate forcep used for nasal turbinate surgery. Clearance of nasal polyp
and antral masses.
Yankauer Eustachian speculum for direct inspection of the Eustachian tube and
nasopharynx during EUA
Yankauer nasophargngeal ST. Clair Thompson nasal speculum
speculum (Nasopharyngospe)
Woakes angular turbinectomy scissors used for turbinectomy
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Woakes angular turbinectomy scissors
Mastoidectomy
Heath mallet and Jankin gouge for removal of cortical bone e.g. mastoidectomy,
Caldwell –luc operation. Also used in fronto-ethmoidectomy.
Heath mallet & Jankin gouge
Colier and Moris currrete for removal of mastoid air cells
Colier and Moris currrete
Tracheostomy
Trousseau dilating forcep has a screw joint and it is bivalve. Used for dilating the
trachea before introducing tracheostomy tube.
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Trousseau dilating forceps
ENDOSCOPY
The first per oral endoscopy was done by Manuel Garcia in 1855 when he used a mirror
and sunlight to visualize his larynx.
Chevalier – Jackson (1865 – 1958) was one of the world leading laryngologists who
developed endoscopes and the art of removing foreign body from the aerodigestive tract.
He graduated from Jefferson Medical College in Philadelphia in 1886 after B.A from
Pennsylvania Western University. His first publication tracheobronchoscopy,
oesophagoscopy, and gastroscopy appeared in [Link] the turn of the 18th century he
invented and introduced distally lighted laryngoscope, bronchoscope, oesophagoscope
plus telescope. He founded a clinic in his name at Temple University and was successful
in removing dangerous foreign bodies with the instruments and techniques he designed.
He was also the first to describe thee Tracheobronchial tree.
His son (Chevalier Lawrence Jackson 1900 – 1961) graduated from Pennsylvania,
specialized in Otorhinolaryngology, worked with his father at the temple clinic and
continued after his father’s retirement. Co- author seven books and inherited some of his
father’s artistic talent.
RECENT ADVANCES IN ENDOSCOSCOPY
Availability of dependable, bright fiberoptic illumination: British optical Physicist
[Link] of Reading University introduced telescope in various degrees.
Kleinsasser and others introduced microlaryngoscopy.
Direct laryngoscopy
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Negus laryngoscope has a twin proximal illumination and sliding panel to allow passage
of instrument after introducing bronchoscope or oesophagoscope. There are two types
namely: 1. Anterior commissure
2. Broad view
Uses: - a. Direct laryngoscopy
b. Modified to pass a bronchoscope (when the sliding panel is removed).
Negus laryngoscope
Negus bronchoscope has a handle, carrier for oxygenation, anaesthetic gas and
fenestration at the sides. Used for bronchoscopy.
Negus bronchoscope
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Negus oesophagoscope. Has a hand with twin light carrier and lamp for proximal
illumination. Beveled distal end and graduated in centimeters. Other instruments that are
used in combination include Patterson grasping and biopsy forceps, Safety pin forceps.
Dental plaque shears and muscle relaxant during anesthesia.
Uses: - for therapeutic and diagnostic oesophagoscopy.
Negus oesophagoscope
Dilation of short segment oesophageal stricture (≤ 2.5cm)
Gum elastic and chevalier Jackson bougies for oesophageal dilatation in patient with
short segment stricture.
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Chevalier- Jackson bougies Gum elastic bougies
Gum elastic bougie is stiffened in either:
a. Ice pack or
b. Chloroform before use