Surgical instrument in ent

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Based on the textbook content, here is a comprehensive overview of surgical instruments used in ENT (Otolaryngology):

Surgical Instruments in ENT

1. Endoscopes

Rigid endoscopes are the cornerstone of modern ENT surgery, especially Functional Endoscopic Sinus Surgery (FESS):

Angle	Use
0°	Standard visualization; used first until skull base is identified
30°	Angled view of sinus cavities
45°	Skull base/sphenoid work
70°	Deep recesses, frontal sinus

In children: flexible 3.2-mm endoscope is preferred
Straight 2.7-mm endoscope used occasionally in pediatric cases
Endoscopes are attached to an endocamera and video monitoring system

2. Powered Instrumentation

Microdebriders (Microsurgical Debriders)

Multipurpose: suction + cutting + irrigation in one instrument
Used for debulking hypertrophic sinonasal mucosa, polyps, and tumors
Cut tissue sharply, minimizing mucosal stripping
Continuous irrigation improves visualization and reduces blood loss
Curved blades and burs can also remove bone (ethmoid cells, frontal sinus drilling)
The 60° blade is commonly used for the frontal sinuses

Drills

Essential in complex sinus surgery and skull base tumor surgery
Extra-long handpieces used with diamond burs of various sizes

3. Specialized ENT Surgical Sets

Stamm Skull Base Instruments (Medtronic)

Slightly longer and thinner than conventional instruments
Have an articulation at the edge for adequate visualization
Used in microendoscopic skull base procedures

Kerrison Micropunch

Used to remove thin, delicate bony plates (e.g., ethmoid air cells near the medial wall of the orbit, bony canal of the optic nerve)

4. Suction Devices

Suction cannulas with blunted edges to avoid mucosal trauma and bleeding
Suction electrocautery for hemostasis

5. Electrocautery

Type	Use
Monopolar	General tissue cutting/coagulation
Bipolar	Safer for delicate structures — anterior/posterior ethmoid arteries, intradural hemorrhage control

6. Hemostatic Agents (used adjunctively)

Surgicel, Spongostam — for bleeding from basilar venous plexus
Bone wax — for bleeding from bone channels
Epinephrine-soaked cottonoids — vasoconstriction and hemostasis

7. Anesthetic/Prep Instruments

Compressed-rayon surgical sponges (cottonoids) soaked in 1:2000 epinephrine
Angulated 25-gauge spinal needle for infiltration of sphenopalatine foramen region

8. Balloon Sinus Dilation

Used for atraumatic dilation of sinus ostia to restore ventilation and drainage
Appropriate for chronic rhinosinusitis with CT-confirmed disease
Particularly effective for frontal sinusitis
Can be used as an adjunct to FESS

9. Robotic Instruments (TORS – Transoral Robotic Surgery)

Used with the da Vinci Robot (Intuitive Surgical):

EndoWrist 5-mm Shetrel grasper
5-mm Maryland dissector
EndoWrist instruments — for tissue manipulation in oropharyngeal/base of tongue surgery
Enables access to areas otherwise requiring open surgery

10. Image Guidance Systems

3D navigation systems providing real-time localization of surgical instruments relative to anatomical structures
Based on preoperative helical CT data
Indicated for:
- Revision sinus surgery
- Distorted anatomy (post-op, traumatic, developmental)
- Extensive sinonasal polyposis
- Disease near skull base, orbit, optic nerve, or carotid artery
- CSF rhinorrhea / skull base defects

Sources:

Cummings Otolaryngology Head and Neck Surgery (Chapters on FESS, Skull Base Surgery, TORS)
K.J. Lee's Essential Otolaryngology

Septoplasty

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Here is a comprehensive overview of septoplasty from Cummings Otolaryngology Head and Neck Surgery:

Septoplasty

Definition & Goal

Septoplasty is the surgical correction of a deviated nasal septum to relieve nasal airway obstruction. The goal — unchanged for over 100 years — is to maximize symptomatic improvement of nasal obstructive complaints while minimizing surgical risk.

Note: Treatment must be individualized — some patients with large deviations have few symptoms, while others with minor deviations are most symptomatic.

Historical Evolution

Era	Technique	Outcome
Late 1800s (Asch)	Closed septal displacement — blunt force to disrupt cartilage attachments	Short-lived improvement; only corrected cartilaginous deviations
Krieg	Mucosal + cartilage resection	Perforations, crusting, worsened obstruction
Ingals (1882)	Mucosal flap elevation + triangular cartilage resection ("window resection")	Foundation for modern technique
Boenninghaus	Resection extended to vomer and perpendicular plate of ethmoid	More comprehensive correction
Modern (SMR → Septoplasty)	Mucosal preservation + selective cartilage/bone removal	Best long-term results

The shift from submucous resection (SMR) to septoplasty reflects the understanding that the septum provides structural nasal support — not just the overlying mucosa.

Anatomy Relevant to Septoplasty

The nasal septum is composed of:

Quadrilateral (septal) cartilage — anterior-inferior
Perpendicular plate of ethmoid — superior
Vomer — posterior-inferior
Maxillary crest — floor

Structural support provided by the septum includes the nasal tip and dorsum — loss of which leads to saddle-nose deformity and tip ptosis.

Indications

Nasal airway obstruction due to septal deviation
Recurrent sinusitis from obstructed drainage pathways
To facilitate access for:
- Functional endoscopic sinus surgery (FESS)
- Turbinate surgery
- Skull base procedures
Combined with rhinoplasty ("septorhinoplasty") for crooked nose correction

Incisions and Plane of Dissection

Standard incision: Hemitransfixion or Killian incision (within the caudal septum area)
Dissection proceeds in the subperichondrial/subperiosteal plane — this is critical:
- Preserves mucosal blood supply
- Reduces risk of perforation
- Allows clean cartilage/bone visualization
Mucosal flaps are elevated bilaterally when needed

Operative Steps (Modern Technique)

Local anesthetic infiltration (with vasoconstrictor, e.g., lidocaine + epinephrine)
Hemitransfixion incision at the caudal septum
Subperichondrial flap elevation on one or both sides
Scoring, morselizing, or excising deviated cartilage — while preserving a dorsal and caudal L-strut (minimum 10–15 mm) for structural support
Bony spur/vomer resection using a chisel or Kerrison rongeur
Cartilage may be reinserted, repositioned, or used as grafts
Quilting sutures or nasal packing to reappose mucosal flaps and prevent hematoma

The L-Strut Concept

The dorsal and caudal struts must be preserved (≥10–15 mm wide) to maintain nasal support and prevent collapse.

Septoplasty and the Caudal Septum

Caudal deviations are the most challenging and most symptomatic
Techniques include:
- Swinging door maneuver — mobilizing the caudal septum out of the maxillary groove and repositioning it in the midline
- Caudal septal replacement with a straight cartilage graft when the native cartilage is unusable
- Securing the repositioned septum with a figure-of-eight suture to the anterior nasal spine or periosteum

Septoplasty With Nasal Valve Correction

Harvested septal cartilage can be fashioned into:
- Spreader grafts — stenting internal nasal valves (placed between the upper lateral cartilages and dorsal septum)
- Batten grafts — bolstering the external nasal valve
Always pre-plan cartilage harvest if valve grafting is anticipated

Septoplasty and the Crooked Nose

Bilateral release of upper lateral cartilages (ULCs) from dorsal septal attachments is required
Releases intrinsic cartilage forces → improves airway + straightens dorsum
May be followed by medial and lateral osteotomies
A single spreader graft can act as a "straightening crutch" at the point of greatest bowing
ULCs are reattached to dorsal septum at closure

Septoplasty With Septal Perforation Repair

Perforation causes turbulent airflow → crusting, bleeding, whistling, saddle-nose deformity
Prevention: immediate intraoperative closure of any mucosal tears; meticulous subperichondrial dissection
Repair: intranasal flaps + connective tissue interposition grafts
- Preferred approach: external rhinoplasty with nasal floor advancement flaps + temporalis fascia or acellular human dermis interposition

Complications of Septoplasty

Complication	Notes
Septal perforation	From bilateral mucosal tears at the same site
Hematoma	Between mucosal flaps; requires drainage
Saddle-nose deformity	From excessive cartilage removal or loss of L-strut
Tip ptosis	Loss of caudal septal support
Recurrent deviation	Intrinsic cartilage memory; inadequate resection
CSF leak	Rare; from inadvertent cribriform plate injury
Nasal valve collapse	Over-resection or injury to ULCs
Anosmia	Rare; olfactory region trauma
Toxic shock syndrome	From nasal packing (rare)

Postoperative Care

Nasal packing or transseptal sutures (preferred — avoid packing complications)
Saline irrigation
Avoidance of nose blowing for 1–2 weeks
Most patients resume normal activity within 1–2 weeks

Source: Cummings Otolaryngology Head and Neck Surgery — Chapter 29: Septoplasty

Foreign bodies are in nose after year what we call

Finding Sources

It is called a rhinolith.

A rhinolith is a calcified mass that forms around a long-standing nasal foreign body (often left for months to years).
Source: K.J. Lee’s Essential Otolaryngology (section noting “Rhinolith: calcareous concretions around intranasal foreign bodies”).

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