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Surgical Procedures II > Test 3 > Flashcards

Test 3 Flashcards

1
Q
A

Nasal speculum (speculae=multiple)

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2
Q

What blade and handle is prefered for septoplasty?

A

15KB on a #7 knife handle

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3
Q
A

Cottle elevator

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4
Q
A

Knight scissors

  • mayo scissors of the nasal world
  • heavy tissue scissors
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5
Q
A

Ballinger Swivel knife

  • resecting cartilage
  • straight or bayonett
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6
Q
A

Boies elevator (Butter knife)

  • reduce turbinates
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7
Q

What do you always have with an osteotome?

A

mallet

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8
Q
A

Takahashi forceps

  • like the debakes of the nasal world
  • atraumatic forceps
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9
Q
A

Blakesley forceps (straight and upbiting)

  • Debakey of the FESS world
  • tip has a little fenestration
  • atraumatic forceps
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10
Q
A

Through-cut forceps (straight and upbiting)

  • True cut
  • ronguer
  • serrated
  • fit into each other
  • like a punch
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11
Q

What is the difference between Blakesleys and Through Cut forceps?

A

Blakesleys are atraumatic and don’t cut tissue. Through Cuts are more like a ronguer or a punch and cut the tissue

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12
Q

Septoplasty (SMR) Instruments Used

A
  • Short & Medium nasal speculae
  • # 15KB on a #15 knife handle
  • Cottle elevator
  • Freer elevator
  • bayonet forceps
  • Knight scissors
  • Frazier suction tip
  • needle holder
  • asdons
  • iris scissors
  • swivel knife
  • Boies elevator
  • Osteotomes with mallet
  • Takahashi forceps
  • carilage crusher (with mallet) or Rubin septal morcelizer
  • Turbinate scissors
  • Jansen-Middleton scissors/rongeur (double action)
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13
Q

Instruments for a FESS

(Functional Endoscopic Sinus Surgery)

(Sinoscopy)

A
  • Short, med, long nasal speculae
  • Sickle knife
  • Right-angle (ball ended) probe
  • Bayonet forceps
  • Backbiters, sidebiters
  • Blakesley forceps
  • Through-cut forceps
  • Frazier suction
  • olive suction tips
  • microdebreider (straight shot)
  • Scope, camera, light cord
  • Giraffe forceps
  • Top-hat forceps
  • sinus irrigation tip
  • Currettes
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14
Q

ENT aka…

A

Otonasolaryngeal

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15
Q

Ears function:

A
  • Hearing
    • last one to leave, first one to come back
  • Equilibrium
  • Position Sense
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16
Q

Anatomy: External Ear

A
  • Externally visible portion– pinna or auricle
  • Histologically– made up of skin and cartilage
    • cartilage grows throughout life, that’s why you get a bigger ears and nose as you get older
  • Opening in pinna= external auditory meatus
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17
Q

Anatomy: Auditory canal

A
  • (external ear)
  • histologically: lined w/ skin, runs through cartilage superficially and bone deep
  • boundaries: external auditory meatus, tympanic membrane
  • specialized glands of proximal auditory canal: ceremonious glands
    • produce: cerumen (ear wax)
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18
Q

Label

A
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19
Q

Anatomy:Tympanic membrane, aka: eardrum

A
  • histologically:
  • inner layer: mucosa
  • external layer: skin
  • middle layer:fibrous connective tissue
  • inferior portion: pars tensa, meaning has fibrous layer–largest portion of the eardrum where the eartube is put in BMT
  • superior portion: pars flaccida, meaning has no fibrous layer
  • tiny skeletal muscles (but behave like smooth muscle) associated with eardrum: tensor tympani
    • function: dampen sound
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20
Q

Middle Ear/ Tympanic Cavity, part one

A
  • Conduction Chamber
  • Path of sound waves entering middle ear from external ear:
      1. tympanic membrane- vibrates
      1. malleus
      1. incus 2-4.=ossicles- tiniest bones in the body
      1. stapes
  • Remember it by MIS (malleus, incus, stapes)
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21
Q

Label

A
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22
Q

Middle Ear, part two

A
  • Pressure equalizer
  • The middle ear is air-filled, and has five anatomical features that serve to equalize pressures in the ear.
  • should not have fluid here, fluid when infected
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23
Q

5 Pressure equalizers in the middle ear

A
  1. laterally: the tympanic membrane
  2. medially, superior: the oval or vestibular window, in which the stapes sits and transmits sound waves to the inner ear
  3. medially and inferiorly: the round or cochlear window, which is closed by the secondary tympanic membrane. The round window allows sound waves being transmitted through the oval window to be dampened once transmitted.
  4. the mastoid antrum, a chamber in the posterior wall of the middle ear, which allows it to communicate with mastoid air cells (spongy cancellous bone-bendy)
  5. The pharyngotympanic, auditory, or eustachian tube runs from the posterior, inferior portion of the tympanic cavity obliquely downward, linking the middle ear with the nasopahrynx. biggest pressure equalizer.
    1. children have a more horizontal eustation tube so fluid can’t drain as well
  • All mucosa in the ear nose and throat is connected. Thats why an infection in one part may affect another
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24
Q

Note about round window

A
  • this is where the pathway of sound ends. sound waves have to come to an end or it would be non stop echoing.
  • blocks soundwaves
  • stops it intantaneously
  • It is a hole in the bone covered by mucous membrane
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25
Q

IMPORTANT NOTE!

A
  • The pharynx and nasopharynx are linked with the Eustacian tube which branches into the middle ear, which leads to the mastoid cells. This means the mucosa that lines all these structures is continuous, making it possible to spread an infection from the throat to the middle ear to the air cells of the mastoid process of the temporal bone.
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26
Q

Inner Ear, aka labyrinth

A
  • Two divisions of the inner ear:
    • Bony Labyrinth, aka osseous labyrinth
      • a system of channels, located within the temporal bone
      • filled with perilymph
    • Membranous labyrinth
      • interconnected membranous sacs located within the bony labyrinth
      • filled with endolymph
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27
Q
A
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28
Q

All receptors in the ear are within the

A

endolymph

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29
Q

Three structures of the inner ear

A
  • the vestibule (small chamber)
  • location: on other side of oval/vestibular window, between cochlea and semicircular canals
  • (egg-shaped; has two parts:
    • saccule
    • utricle
      • each of these contain a receptor: macula(e))
  • In the membranous labriynth of the vestibule the receptors are called the macula(e)
    • ​the macula are responsible for linear motion
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30
Q

semi-circular canals

A
  • have canals in all three planes of space
  • Membranous portion= semicircular ducts, have receptors called crista ampullaris
    • In the membranous portion of the semicircular canals, the receptors are called crista ampullaris
    • crista ampullaris is responsible for rotational motion
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31
Q

the cochlea

A
  • snail-shaped
  • membranous portion: cochlear duct; houses Organ of Corti, primary receptor for hearing
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32
Q

Label

A
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33
Q

Pathway of Sound

A
  • Auricle (Pinna)
  • External auditory meatus
  • External auditory canal
  • Tympanic membrane (eardrum)
  • Ossicles
    • Malleus
    • Incus
    • Stapes
  • Oval window
  • Vestible
  • Cohlea (membranous labryinth)
  • Organ of Corti
  • Round window
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34
Q

ACCESSORY ANATOMY

A
  • Important to note due to its proximity to the anatomy so far discussed, but not actually part of the ear, is the facial nerve. The facial nerve covers a lot of territory, making it vulnerable to surgical complications during the bony part of middle and inner ear surgery, as well as parotidectomy.
  • it’s fucking everywhere
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35
Q

Conduction Hearing Loss Definition:

A
  • The blocking of the mechanical motion caused by sound waves, usually in the external and middle ear
  • blocking of waves
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36
Q

Causes of Conduction Hearing Loss

A
  • Otitis media, aka middle ear infection
  • Tympanic perforation caused by otitis media or trauma
  • Trauma to or congenital malformation of ossicles
    • Trauma more common
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37
Q

Causes of Conduction Hearing Loss part 2

A
  • Cholesteatoma/ossicular chain erosion/otosclerosis(hardening of stapes footplate)
  • A series of conditions may lead to this:
    • chronic otitis media
    • chronic mastoiditis
    • formation of saclikelike mass (cholesteatoma) containing keratin shed by mucosa
    • mass becomes a lesion, which erodes temporal bone, possibly ossicles
    • New temporal bone is cortical and overgrows into antrum, and may fix ossicles in place, especially stapes footplate, limiting sound wave conduction in middle ear
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38
Q

Sensorineural hearing Loss Definition:

A
  • The inability to receive a stimulus originating in the inner ear, either due to nonfunctioning receptors or absent nerve impulses to the brain, or both.
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39
Q

Causes of Sensorineural hearing loss, part I

A
  • Acoustic Neuroma, aka Vestibular Schwannoma
    • Definition: A benign tumour of Schwann cells of the acoustic or vestibulocochlear nerve.
    • It is surgically resected even though benign because it causes equilibrium problems
    • Facial nerve may also become involved
    • Most common symptoms: unilateral tinnitus or ringing of ears, unilateral hearing loss
    • Other symptoms are also neurological and range from vertigo to coma
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40
Q

Causes of Sensorineural hearing loss, Part 2

A
  • Genetic : 50% of deafness in children has a genetic basis. May be due to inadequate acoustic nerve fibers, a lack of hair cells in the Organ of Corti, or a problem in the auditory pathways in the brain.
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41
Q

Causes of Sensorineural hearing loss, part 3:

A
  • Trauma
    • Acute: tympanic membrane ruptures with force, transmits force to inner ear, rupturing labyrinth membrane–causing endolyph to drain out
    • Chronic: high decibel levels causing gradual death of hair cells
  • Meniere’s Disease
    • Over-accumulation of endolymph–pressure too high
    • men 50-60
    • aka endolymphatic hydrops
    • Common symptoms: tinnitus, dizziness, progressive deafness.
    • Cause is unknown
    • Non-surgical–
      • low salt diet
      • bed rest
      • beta blockers
      • antidepressants
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42
Q

Myringotomy

A
  • Definition: An incision into the pars tensa of the tympanic membrane, usually with subsequent placement of a pressure-equalizing plastic tube, aka myringotomy tube.
  • Indications: A middle ear infection that causes conductive hearing loss and which does not resolve spontaneously or with the use of antibiotics over an 8-12 week period. Most patients requiring this procedure are children, although adults may also contract severe otitis media and need it as well.
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43
Q

Myringotomy Procedure

A
    1. First, a speculum is placed by the surgeon into the operative ear. A microscope is brought into focus just above it.
    1. The ear canal may need to be suctioned. Then, cerumen is removed from the canal with a cerumen curette. Often the suction is reapplied to better visualize the tympanic membrane.
    1. The myringotomy knife is then used to make the tympanotomy, and the middle ear is suctioned through the resulting defect in the membrane.
    1. The plastic myringotomy tube is placed within alligator forceps, and then the tube is inserted into the tympanotomy. If the tube needs to have its angle adjusted, a Rosen needle or angled pick may be used.
    1. Antibiotic drops are applied, and cotton is placed in the external auditory meatus.
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44
Q

Simple Tympanoplasty (aka Myringoplasty)

A
  • Definition: the repair of the tympanic membrane.
  • Indications: Myringotomy site that did not heal properly, or infection or trauma leading to tympanic membrane perforation
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45
Q

Simple tympanoplasty procedure

A
    1. As in myringotomy, a microscope is needed.
    1. the tympanic membrane is visualized and any epithelium present around the perforation is removed.
    1. A paper patch is placed over the perforation if it is relatively small.
    1. For larger perforations, a temporalis fascia graft may be harvested through a post-auricular incision first, and used in place of a patch. The other option is an allograft, usually decellularized skin.
    1. Once the patch is aligned properly, it is “sealed” in place with small pieces of Gelfoam soaked in antibiotic solution. This dissolves within 2 weeks, by which time healing has hopefully occurred .
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46
Q

Tympanoplasty with Ossicular Chain Reconstruction

A
  • Definition: the replacement of a nonfunctioning ossicle or ossicles with artificial implants or graft material, and the possible repair of a perforated tympanic membrane.
  • Indications: Trauma from forcefully perforated eardrum, including lightning strike, a temporal bone fracture resulting in a tympanic membrane tear and/or ossicle displacement, and rarely, congenital malformation of ossicles
  • Two types of incision :
    • ​Postauricular: NOT for access to middle ear; used to harvest temporalis fascia graft.
    • Transcanal: Incision in skin of distal canal reflects tympanic membrane away from middle ear, exposing ossicles
    • May replace all or part of the ossicular chain
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47
Q

Stapedectomy/Stapedotomy

A
  • If otosclerosis or congenital malformation has caused the stapes footplate to become fixed in position, one of these is indicated.
  • Stapedectomy: removal of entire stapes, including footplate, and replacement with prosthesis.- this may be posted on board but really mean stapedotomy
  • Stapedotomy: removal of proximal portion of the stapes, creating an opening in footplate, and placing prosthesis which restores ossicular movement- way more common
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48
Q

Transcanal Stapedotomy

A
  1. The ossicular chain is tested for motion
  2. The proximal stapes is removed
  3. The stapes footplate is opened
  4. Graft material (temporalis fascia) covers the opening of the footplate
  5. The prosthesis is placed onto the incus
  6. The prosthesis resting on the graft
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49
Q

Mastoidectomy

A
  • Indications: Chronic otitis media causing cholesteatoma, which erodes mastoid antrum of temporal bone, and may progress to ossicles.
  • Incision: Postauricular
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50
Q

Mastoidectomy Definitions

3 types

A
  1. Simple Mastoidectomy: The removal of diseased mastoid portion of temporal bone, leaving ossicles intact.
  2. Modified Radical Mastoidectomy: Removal of diseased bone which includes the mastoid, part of the bony canal of the ear, and one or more ossicles. The tympanic membrane is spared as are any healthy ossicle(s), and an ossicular prosthesis is placed.
  3. Radical Mastoidectomy (rare) All ossicles, the entire bony canal wall and diseased bone of mastoid are resected. Usually the auditory canal is so widened that the tympanic membrane cannot stretch to cover it. Hearing may be lost. An attempt may be made to restore hearing with OCR and extensive grafting to fabricate a new tympanic membrane. The other option is BAHA.
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51
Q

Cochlear implants Definition:

A
  • The placement of a prosthetic hearing device designed to correct profound sensorineural hearing loss.
  • usually for young kids 1-2 years old if born deaf
  • adults later in life with hearing loss or profound sensorineural deafness
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52
Q

Cochlear Implant Notes

A
  • The internal receiver is placed into a recess drilled into the mastoid cavity
  • A cochleostomy is performed, and an electrode is placed within the membranous labyrinth
  • The electrode is connected to the internal receiver
  • The inner receiver communicates with an external one worn behind the ear.
  • The patient must commit to an education process that will help him or her understand and interpret the new sound he or she is hearing.
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53
Q

BAHA Bone-anchored hearing aid Definition:

A
  • The placement of a prosthetic hearing device designed for conduction hearing loss that is not correctable by ossicular chain reconstruction or whose external hearing aids are of limited benefit.
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54
Q

BAHA Procedure notes

A
  • A hole is drilled in the temporal bone, posterior to the pinna.
  • The device is anchored within the recess in the bone and the incision is closed, leaving an abutment port exposed, into which an external receiver may be “snapped” in.
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55
Q

Removal of Acoustic Neuroma

A
  • benign tumor pressing on nerve
  • The surgical excision of the diseased Schwann cells of the vestibular portion of the 8th cranial (vestibulocochlear) nerve.
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56
Q

Acoustic Neuroma Procedural Notes

A
    1. A mastoidectomy is performed, and all the semicircular canals are excised with a drill. A small wedge of bone between facial and superior vestibular nerves is removed.
    1. An incision is made into the dura, and the tumor is carefully dissected away from the nerve.
    1. Once the tumor is removed, fibrin glue is used to reseal the dura, and the hole in the mastoid is packed with graft material.
  • 4.The wound is closed.
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57
Q

Endolymphatic Sac Decompression Definition

A
  • A surgical treatment for Meniere’s Disease in which bone surrounding the endolymphatic sac is resected. The membranous labyrinth may also be incised to allow a shunt to be inserted to drain fluid from the inner ear. The shunt leads from the endolymphatic sac of the inner ear to the CSF of the cochlear aqueduct or the mastoid process of the temporal bone.
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58
Q

Labyrinthectomy, aka Cochleotomy

A
  • Definition: A surgical treatment for Meniere’s Disease in which the mastoid is drilled down to the membranous labyrinth, part of which is obliterated, in order to drain endolymph. This procedure destroys hearing in the affected ear.
  • Indications: Meniere’s Disease and poor hearing in the affected ear
  • This is old school and is going away
  • for someone who needs releif immidiately
  • drilling into cochlea and draining
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59
Q

GENERAL TIPS AND REMINDERS FOR OTOSURGERY

Positioning:

A
  • Head of patient is usually at the foot of the bed for all cases except myringotomy. The patent’s head is at anesthesia for induction, but once general anesthesia is initiated, the bed is turned 180 degrees. A long anesthesia circuit is needed.
    1. Most procedures will use a gel donut for a headrest.
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60
Q

GENERAL TIPS AND REMINDERS FOR OTOSURGERY

Anesthesia

A
    1. For most ear procedures the patient will be under general anesthesia.
  • 2. During ossicular chain reconstruction, help to remind anesthesia to discontinue use of nitrous oxide. This gas diffuses into the ear chambers, distending them slightly. Turning it off ensures proper placement of the implant.
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61
Q

GENERAL TIPS AND REMINDERS FOR OTOSURGERY

Prep

A
    1. Usually no shave unless specified by surgeon or for BAHA.
    1. Margin of prep should be at least one inch around the ear circumferentially. The external auditory meatus is cleaned with CTAs. It remains up to Dr. preference if Betadine is to be dropped into canal or not.
    1. Some surgeons may have a preference that the face be prepped out, and that a clear Steri drape (ie 1010 drape) be placed over the face to watch for facial nerve disturbances.
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62
Q

GENERAL TIPS AND REMINDERS FOR OTOSURGERY

Common solutions on field

A
    1. Water: to keep an instrument wipe damp, in order to wipe each micro instrument after each use
    1. Saline: For irrigating outside the middle ear
    1. Tissusol/Physiosol: Has the same osmolarity as endolymph. May use for irrigant in middle/inner ear cases.
    1. Epinepherine: Usually mixed with injectable saline, this is used to place on cotton balls for hemostasis
    1. Floxin otic suspension: the most common antibiotic suspension used for packing material (ie Gelfoam) or direct application after myringotomy
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63
Q

GENERAL TIPS AND REMINDERS FOR OTOSURGERY

Post-op Care

A
  • Any procedures involving drilling in the mastoid process (BAHA, cochlear implant, mastoidectomy) should avoid coughing and sneezing postop.
  • Any middle/inner ear procedure patients should also avoid swimming and air travel for 1-2 weeks postop.
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64
Q

GENERAL TIPS AND REMINDERS FOR OTOSURGERY

Best Practice

A
    1. Limit lint in middle or inner ear procedures. This means no or low-linting drapes, cottonoids used instead of cotton balls, powderless gloves.
    1. One thing the surgical tech can do to help with limiting debris in the ear is to religiously wipe each micro instrument after each use, to keep suction tips flushed, and to hand wash each micro instrument with an instrument wipe after the case is over.
  • 3. NO MICRO INSTRUMENTS SHOULD EVER GO THROUGH THE WASHER-STERILIZER!!!
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65
Q

FUNCTIONS nose

A
  • Primary: prepare inhaled air for use in the lungs by three methods
    • warming
    • filtering
    • moisturizing
  • Secondary: olfactory-smell
  • Tertiary: the functions of the paranasal sinuses: reduce weight of cranium; resonating chamber for vocal tones
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66
Q

External Nasal Structure

A
  • Slopes away from face at the nasal bones
  • All other supporting framework is made of cartilage
  • Major cartilaginous structures:
    • nasal septal cartilage
    • nasal septal lateral processes
    • alar cartilage
    • Divides nostrils, inferior to septum: collumella
  • nasal cavity is separated into right and left nares by the nasal septum, made up of:
    • mucosa
    • nasal septal cartilage
    • ethmoid bone (perpendicular plate)
    • vomer bone
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67
Q

External Nasal structure, part 2

A
  • The nasal cavity is separated from the mouth by the palate.
  • Nasal cavity is separated from brain by the ethmoid bone.
  • Within each nasal cavity are three turbinates, aka concha. There are three to a side: gutters
    • inferior
    • middle
    • superior
  • Note: all sinuses drain to an opening or meatus associated with one of the three turbinates, in properly-functioning noses.
  • all mucosa is continuous
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68
Q

The internal nose or paranasal sinuses

A
  • Definition: Air-containing spaces that open into the nasal cavities
  • The nasal sinuses are lined with mucosa, and are all continuous with each other as well as the pharynx, which is continuous with the middle ear via the eustachian tube.
  • There are 4 pairs of paranasal sinuses.
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69
Q

Maxillary Sinuses

A
  • Location: on either side of external nose, in maxillary bone
  • The largest of the paired sinuses
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70
Q

Ethmoid Sinuses

A
  • There are three (varies) chambers of the ethmoid sinuses on each side
  • The bony part of the middle turbinate is an extension of the ethmoid bone.
  • The perpendicular plate of the ethmoid makes up part of the nasal septum.
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71
Q

Sphenoid Sinuses

A
  • The deepest of the sinuses
  • Parts of the sphenoid are very close to the optic nerve and the pituitary gland
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72
Q

Frontal Sinuses

A
  • Located superiorly to other sinuses
  • The smallest of all the sinus chambers
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73
Q
A
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74
Q

Pathology of the External Nose

A
  • Deviated septum: may be due to:
    • Congenital defect
    • Trauma
  • Turbinate hypertrophy–overgrowth, trouble with breathing usually middle or inferior turbinates
  • Nasal polyps
  • Choanal atresia
    • congenital blockage from nose to nasopharynx
    • can’t breath through nose
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75
Q

Pathology of the Sinuses

A
  • Sinusitis: usually caused by allergies or chronic URI. Results in a thickened mucous membrane which may result in:
    • Polyps: along with thickened mucous membrane, may lead to:
    • Nonpatency of sinus drainage
    • Fungal Infection
  • Bleeding: Due to: trauma or recent sinus or nasal surgery
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76
Q

CLOSED REDUCTION OF NASAL FRACTURE

A
  • Definition: the reduction of cartilaginous and or bony fracture of the nasal septum without incising the mucosa.
  • Indication: traumatic nasal fracture
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77
Q

Closed Reduction of Nasal Fracture: Procedure

A
  • 1.Cottonoids soaked in cocaine or Afrin may be inserted into the nose and allowed to sit for 1-2 minutes, before lidocaine with epinephrine is injected on both sides of the septum.
  • 2.With a Boies elevator, the nasal septum is forced back into a close approximation of its former anatomic position.
    1. Resulting bleeding is suctioned, and then cottonoids are replaced to tamponade the effect and to provide vasoconstriction.- main concern bleeding
    1. An external splint is applied.
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78
Q

SEPTOPLASTY, aka Submucous Resection (SMR)

A
  • Definition: The correction of a deviated nasal septum through an incision in the nasal septal mucosa, with resection of some of the deviated tissues
  • Indications: traumatic or congenital septal deviation
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79
Q

Septoplasty Notes

A
  • Incision: Inside right nares, on the septal mucosa, parallel with and about 1 cm superior to the collumella.
  • The deviated portion of the septum is resected, straightened, and reimplanted.
  • Internal splints coated in antibiotic ointment are applied and sutured in place after the incision is closed.
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80
Q

TURBINATE REDUCTION

A
  • Definition: the partial or full resection of one or more pairs of turbinates, usually the inferior and middle turbinates.
  • Indications: turbinate hypertrophy causing obstructed breathing.
  • Methods:
    • Cryoablation
    • Coagulation
    • Wedge resection followed by coagulation-oldschool
    • Microdebreidement- straigh shot, 2mm blade
81
Q

Nasal Polypectomy

A
  • Done endoscopically with sinoscopy scope
  • Most often a microdebrieder is used to removed polyp
82
Q

Choanal atresia repair

A
  • May be transnasal or transpalatal depending on defect
  • Usually done using endoscope
  • If a bilateral bony atresia, stents are placed and repeat surgery is needed as child grows
  • usually a kid/teenager
  • nasal set & kerrison punch
83
Q

CALDWELL - LUC PROCEDURE

A
  • Definition: Incision into canine fossa of upper jaw and exposure of bony antrum of maxilla for removal of diseased bony portions of antral wall and contents of maxillary sinus to establish a large opening in the inferior meatus of the sinus cavity.
  • Indications: historically, a nonpatency of the maxillary sinuses into the meatus below the inferior tubinate. Since the advent of FESS, only used when large portion of bone needs to be removed or bone is too hard to be penetrated by a microdebreider.
84
Q

FESS(Aka ESS, Sinusocopy)

A
  • Definition: the endoscopic visualization of the paranasal sinuses, with indicatated operative procedures
  • Indications: Chronic sinusitis with polyp formation, nonpatency of nasal sinuses, fungal infection of the sinuses.
  • can be image guided
85
Q

FESS Procedure

A
  • To create a nasal antral window, aka nasal antrostomy, which is the purpose of a Caldwell-Luc procedure, normally the missing meatus is probed for through mucosa with a right-angled probe. When the declivity is found, it may be widened with a backbiter, or opened with the use of a curved microdebreider blade.
  • For removal of polyps: anything that is easy to identify and reach with the micrdebreider is resected this way. For difficult angles, giraffe forceps may be used. In the ethmoid and sphenoid sinuses, when near fat pads of the eye or the brain, blakesly or giraffe forceps may be used.
  • For removal of fungus-infected hardened mucus: Usually use sinus irrigation and blakesly, Takahashi, duckbill forceps
86
Q

Tips for FESS

A
  • During FESS: if you can see the light of the sinusocpe behind the medial canthus of the eye, watch the eye, and tell the surgeon if it moves, especially anteriorly!
  • When resecting polyps from behind the eye or close to the brain, most surgeons do not use the debreider, in order to be safer about the resection.
  • Always keep a cup of saline on your mayo. Whatever specimens you get, place them in it. If they sink, they are “safe”: ie fungus, mucosa, bone, etc. If they float, they are fat (fat pads behind eyes) or brain.
87
Q

Helpful Hints for Nasal and Sinus Surgery

A
  • Positioning:
    • Usually supine with arms tucked so surgeon can have access to head. Some surgeons prefer an eye bed for this reason.
    • Often use gel donut for head
  • Localization:
    • For most nose cases, set up a “nasal anesthesia mayo”, with cottonoids soaked in cocaine or Afrin, bayonet forceps, hypo and syringe loaded with lidocaine with epi, and surgeon’s gloves.
  • Prep:
    • Some doctors will have the tech prep with chlorhexadine soap and a raytec sponge.
    • Others require no prep.
    • There is never a prep inside the nose
  • Draping:
    • many surgeons like to start with a “turban drape”: two towels and a towel clip.
    • Usually tape eyes for a septoplasty, lube only for a FESS.
    • Dressing:
      • 2x2 “moustache” under nose
88
Q

Oral Cavity

A
  • Top of oral cavity can also be divided into 2 parts:
    • Hard Palate: anterior portion
    • Soft Palate: extends to become the uvula
89
Q

Pharynx

A
  • the pharynx can be divided into 3 sections:
    • nasopharynx
    • oropharynx
    • laryngopharynx
90
Q

Nasopharynx

A
  • Begins at the posterior portion of each nasal cavity.
  • Structures of the nasopharynx include:
    • entrance of Eustachian tube, leading to middle ear
    • Pharyngeal tonsils, aka: adenoids, are at the inferiormost aspect of the nasopharynx as it leads into the oropharynx.- one mass of tissue
    • Note: adenoid tissue is usually its largest in childhood (fighting off infection), and may shrink to nonexistence in adulthood. The location of the adenoid(s) behind and above the uvula makes them viewable only with an angled mirror from the oral cavity.
91
Q

Oropharynx

A
  • Houses the pallentine tonsils, aka tonsils, and is continuous with the oral cavity
92
Q

Laryngopharynx

A
  • Posteriorly continuous with esophagus.
  • Anteriorly continuous with larynx.
93
Q

Larynx

A
  • The larynx angles inferiorly and anteriorly away from the pharynx and is continuous with the trachea.
  • Its structures include three single cartilages and three paired cartilages.
94
Q

Single Cartilages of the Larynx

A
  • Thyroid cartilage, aka Adam’s apple
  • Cricoid cartilage:The ring of cartilage that is just inferior to the thyroid cartilage. This is the surgical landmark that marks the inferiormost aspect of the larynx. This is also the area where pressure is applied during induction of anesthesia to close off the esophagus and prevent regurgitation in the following patients:
    • those not NPO
    • emergency surgery
    • hx of GI problems
    • pregnant patients
  • Epiglottis: a leaf-like flap of cartilage that swings down to cover the trachea when swallowing.
95
Q

Trachea, aka windpipe

A
  • The trachea is made up of 16-20 incomplete rings of cartilage.- has to do with how long your neck is, incomplete because your esophagus is right behind it
  • Running just medial to the trachea on either side are the paired recurrent laryngeal nerves.
96
Q

Salivary Glands

A
  • There are two types of salivary glands:
    • Endogenous: these are located within the mucosa of the oral cavity, and are smaller accessories.
    • Exogenous: outside the oral cavity, these are the largest of the salivary glands.
97
Q

Exogenous Salivary Glands

A
  • Sublingual: located below the tongue, and open onto the oral cavity near its base.
  • Submandibular: located just inferior to the mandible, the ducts from the submandibular glands open at the frenulum of the tongue.
  • Parotid: the largest of the salivary glands, the paired parotids produce 25% of saliva. The parotid lies just inferior to the zygomatic arch and posterior to the ramus of the manidible. Its duct empties into the bucchal cavity. The parotid can be divided into 2 parts:
    • Superficial: lies anterior to facial nerve
    • Deep: lies posterior to facial nerve
98
Q

Mouth Pathology

A
  • Sialolith, aka Salivary stone
    • Most common location for this is in the duct leading from the submandibular gland to the oral cavity.
  • Cancer of tongue, gums, etc.
    • This is usually due to the use of chewing tobacco, but may be from other causes
99
Q

Tonsillitis

A
  • A chronic inflammation of the pallantine tonsils, usually due to chronic throat infections.
100
Q

Adenoiditis

A
  • A chronic inflammation of the pharyngeal tonsil. More common in children, since there is more of this tissue present in them.
101
Q

Sleep apnea

A
  • Contributing factors include:
    • Adenoiditis or adenoid hypertrophy
    • Tonsillitis
    • Elongated uvula
    • Atrophied soft palate
    • Obesity
  • Signs and symptoms of sleep apnea include:
    • Snorting in sleep
    • Gasping in sleep
    • Heroic snoring
    • Daytime sleepiness
    • O2 sat of 70-80% if tested by sleep study
102
Q

Thyroglossal duct cyst

A
  • Thyroglossal duct is the route thyroid tissues take to migrate from their origin in the oropharynx to the location of the thyroid in the neck during embryological development.
  • When this duct does not close, a cyst can form (in childhood or adulthood).
  • Thyroglossal duct cysts can be precursors to cancer, and should be excised.
103
Q

phonation

A

productin of sound

104
Q

Larynx and Trachea Pathologies

A
  • Polyps/ Nodules of the larynx and vocal cords: Any lesions on vocal cords may interfere with speech. Polyps may be benign or cancerous. Stripping lesions from vocal cords may permanently alter voice.
  • Laryngeal Cancer: usually a result of smoking
105
Q

Tracheostomy vs. tracheotomy

A
  • Often these terms are used interchangeably
  • A permanent tracheostomy exteriorizes the trachea via circumferential sutures, creating a permanent stoma.
  • Most commonly a permanent tracheostomy is done after laryngectomy due to throat cancer.
106
Q

Tracheostomy

A
  • Definition: The fashioning of a patent airway by creating a hole in the trachea, and the insertion of a tube therein.
  • Indications: Non-patent airway or prevention of future non patent airway*
  • Note: emergent and non-emergent (airway in place, intubated) procedures vary.
107
Q

Tracheostomy Notes

A
  • In an emergency, access to the trachea is often obtained by
  • cricothyroidotomy into the larynx, creating an aperture between the cricoid cartilage and thyroid cartilage. At this level, tissues are thinner, and superior to thyroid tissue, so less dissection is needed.
  • after tracheostomy, the obturator must ALWAYS be sent with the patient! why? if trach shoots out need to put back in easily
  • Due to its proximity to the trachea, there is a risk of recurrent laryngeal nerve injury.
  • As the tech, you should ALWAYS test the cuff on the tracheostomy tube before handing it to the surgeon.
  • tech can tie one side of the tube around neck but surgeon needs to do the other
108
Q

Tonsillectomy/Adenoidectomy

A
  • Definition: Surgical resection of the pallantine and pharyngeal tonsils.
  • Indications; tonsillitis, adenoiditis.
  • Notes:
    • Patient’s mouth is suspended from mayo
    • Surgeon is using electrocautery near the airway
    • Usually, tonsils are sent together as one specimen
    • Some bleeding will occur 5-6 days postop as eschar sloughs off.
109
Q

UPPP (aka Uvulopharyngoplatoplasty) (U3P)

A
  • Definition: A surgical treatment for sleep apnea, in which tonsils, uvula, and a portion of the soft palate are resected.
  • Indications: proven presence of sleep apnea in which nonsurgical treatment has failed.
110
Q

UPPP Procedure Notes

A
  • If tonsils are still present, these are resected. Also, the posterior soft palate and uvula are resected
  • The mucosa anterior and posterior to the resected portion are approximated (sutured together)
  • Note: A risk for this procedure is airway obstruction due to swelling or hematoma at incision site. Therefore it is imperative that these pts are monitored closely postoperatively.
111
Q

Thyroglossal duct cystectomy

A
  • The surgical excision of a thyroglossal duct cyst, which is its only treatment.
  • Thyroglossal duct cysts are found in the midline of the neck, usually deep to the thyroid isthmus. Most have a portion within the hyoid bone
112
Q

Setting up for a thyroglossal duct cystectomy

A
  • Think of what you would need for a thyroidectomy (ie, peanuts, fine dissectors, thyroid and green retractors, ultrasonic or other ligating instrument, ties, possible nerve monitor or stimulator, etc.)
  • Add a way to resect the midline of the hyoid bone (bone cuttters for children, small powered saw for adults).
113
Q

Larygoscopy, Esophagoscopy, Bronchoscopy

A
  • Definition: Endoscopic visualization of the named structure. Triple endoscopy means all three.
  • Indication: Need for biopsy of lesion or visual inspection of named structure.
114
Q

Parotidectomy

A
  • Most parotid tumors are benign but will impinge in facial nerve if unresected
  • Superficial: resection of parotid lying above facial nerve
  • Total: resection of entire parotid
  • Due to presence of facial nerve, nerve monitoring, bipolar electrocautery, and clear drape to view nerve twitches are best practice
115
Q

A VERY IMPORTANT NOTE ABOUT LASERS IN THE AIRWAY

A
  • ALWAYS HAVE:
  • Water
  • Laser-approved ET tube (usually clad in stainless steel or copper)
  • Room air and no O2 when lasering!
  • Most common laser combination for larynx/vocal cords: CO2 and helium-neon
116
Q

Optic globe and surrounding structures

A
  • The optic globe is contained in the orbit of the skull.
  • Bones surrounding and protecting the orbit of eye
    • Frontal
    • Maxillary
    • Zygomatic
    • Lacrimal
    • Sphenoidal
    • Ethmoidal
    • Palatine bones
117
Q

EYELIDS

A
  • Palpebrae (eyelids) – Two moveable musculofibrous folds in front of orbit to protect the globe and eye from light.
  • The space between the upper and lower lids is the palpebral fissure. The angle where lids meet is the canthus (medial or lateral). Posterior to lashes is a row of glandular orifices – meibomian glands secrete serus moisturize
  • Medial edges have punctum lacrimale. The eyelids distribute secretions to keep the cornea moist and wash away foreign materials.
118
Q

CONJUCTIVA and LACRIMAL APPARATUS

A
  • The conjunctiva is a sac that lines the eyelid and anterior part of the sclera (white of the eye) to protect the eye from drying.
  • Lacrimal gland is source of serous secretions, or tears. The lacrimal gland, located in the orbit superiorly and laterally to the eyeball. Tears drain into nose via nasolacrimal ducts.
  • Pink eye– conjunctiva gets irritated lines eye except cornea
119
Q
A
    1. Lacrimal gland releases tears
    1. Tears wash over eyeball
    1. Tears leave eye via lacrimal duct
    1. Wash down into nasolacrimal duct
120
Q

EYEBALL

A
  • The eyeball has 3 coats (or layers):
    • Outermost layer = sclera and cornea
    • second layer = choroid, ciliary body and iris
    • retina
121
Q

Outermost layer – Sclera and Cornea

A
  • Sclera– the outermost layer made of firm tough connective tissue. “White of the Eye”. It’s strong elastic properties maintain the shape of the globe. The sclera is continuous with the dura mater that covers the optic nerve. The scleral structure becomes the transparent, avascular cornea anteriorly
  • need cutting needle to suture
122
Q

Outermost layer – Sclera and Cornea

A
  • Cornea– “Window of the eye”. It bulges forward slightly and is the most important refracting structure. Composed of five layers.
  • The cornea is avascular and gets its nutrients and O2 supply from diffusion from blood vessels of sclera, aqueous humor, and tears.
  • The point where sclera joins cornea – limbus.
123
Q

distortions in shape of cornea=

A

blurred vision

124
Q

Uveal tract (Middle layer)

A
  • an incomplete ball– gaps at the pupil and optic nerve.
    • Choroid – composed of delicate network of connective tissue interlaced with many blood vessels.
    • Ciliary Body – extension of choroid layer. It has smooth muscle and secretory function.
    • Iris – a thin membrane that is the anterior portion of middle layer. It is situated in front of the lens. It is the colored part and composed of two types of muscle. The iris has a central opening called the pupil (like a camera).
125
Q
A
126
Q

Internal Layer

A
  • Retina is the nervous covering, it has ten layers of nerve cells– including rods and cones. Three cones (red, green, blue) for color and rods for black and white.
  • The retina has two parts.
    • Outer pigmented layer, and
    • inner neural layer. Neural retina covers inner aspect of the posterior 2/3 of eye. (when doing vitrectomy don’t go into nueral layer)
  • Posterior retina is continuous with optic nerve.
127
Q

The point of which the nerve enters the eyeball is the

A

optic disc. This is the anatomical blind spot. The point of highest resolution is the macula fovea pit.

128
Q

Vitreous humor

A
  • a gel like substance that fills the entire space behind the lens and keeps the eyeball in its spherical shape and aids in refraction.
129
Q

Refractive Apparatus

A
  • • bending light at an angulated surface
  • Cornea, aqueous humor, lens and vitreous body. Cornea has greatest refractive power.
  • Variations in curvature change it’s power.
130
Q

Lens

A
  • avascular, transparent, biconvex and has a diameter of 1 cm. A thin, homogenous and highly elastic carbohydrate containing lens capsule is attached to the ciliary body by delicate radial ligaments, called zonules, which holds the lens in place. Contractions of ciliary bodies expands and retracts lens for accommodation. (focusing from far away)
131
Q
A
132
Q

Musculature

A
  • – extrinsic ocular muscles of the eyeball are four rectus and two oblique muscles. Six striated muscles are inserted into sclera via tendons.
  • Rectus : Medial, lateral, inferior and superior (when one retracts, the other relaxes)
  • Oblique: Superior and inferior. Insert on lateral posterior quadrant of eyeball. (rolling eyes)
133
Q

Nerves

A
  • The extraocular muscles are innervated by three cranial nerves:
    • A.Trochlear (IV): innervates superior oblique
    • B.Abducens (VI): innervates lateral rectus
    • C.Oculomotor (III): innervates remaining four
  • Optic nerve (II) extends between the posterior eyeball and optic chiasma.
134
Q

Blood Supply eye

A
  • Ophthalmic artery, a branch of the internal carotid artery, is the main arterial supply to the orbit and globe. Central retinal artery and vein travel through optic nerve and provide an independent circulation to inner retina.
135
Q

Visual Pathway

A
  • Optic nerve, optic chiasma, lateral geniculate body of thalamus, optic radiations, and visual cortex of occipital lobe
  • Nasal portion of retinal cross at chiasma.
136
Q

Vision

A
  • In order for vision to occur, two conditions must be exist:
    • An image must be formed on the retina, to stimulate its visual receptors, and
    • the resulting nerve impulses must be conducted to the visual areas of the brain.
137
Q
A
138
Q

Laser-Assisted In Situ Keratomileusis (LASIK)

A
  • A corneal flap is created using a microkeratome. The stromal layer of the cornea is reshaped with an excimer laser. The flap is replaced.
139
Q

Tumors on the lid or within the globe

A
  • Hordeolum ( stye) caused by infection of the sebaceous gland of the eyelid (mabomium glands)
  • Chalazion is a small nodule formed due to fatty degeneration of hordeolum
140
Q

Pterygium

A
  • a benign growth of conjunctival tissue over corneal surface.
  • obstructs vision
141
Q

Entropian

A
  • the eyelid (usually the lower lid) folds inward. It is very uncomfortable, as the eyelashes constantly rub against the cornea and irritate it
142
Q

Entropian Procedure

A
  • A marginal strip of lid is overlapped to estimate the amount of lid shortening.
  • A tarsal incision is made, and 4-0 traction sutures are placed in the conjunctiva and lower lid. The redundant tissue is removed.
  • Double-arm sutures are passed anterior to the tarsal plate and through the skin inferior to the lashes.
  • The lid margin is closed.
143
Q

Ectropion

A
  • the lower eyelid turns outwards.
144
Q

Ectropion procedure

A
  • A= Before surgery
  • A skin flap is raised, and redundant tarsal tissue is removed.
  • The area of resection is measured
  • Completed closure.
145
Q

Lacrimal Apparatus: Obstruction/Disruption

A
  • Obstruction may be caused by:
    • Calculus (stone), U.RI., Trauma (such as Laceration – Dog bite is common with children and Blunt –Broken nose. ), or Congenital deformity – seen in infants & young chldren.
    • DCR –DacryoCystoRhinostomy - establishment of anew tear passageway for drainage into nasal cavity..
146
Q

DCR –DacryoCystoRhinostomy Procedure

A
  • The medial canthal tendon is exposed, and the orbicularis muscle is separated at the point of insertion.
  • The periosteum is incised and reflected back.
  • The canthal tendon and lacrimal sac are retracted to expose the lacrimal fossa.
  • Bone is removed.
  • The bony osteum is formed
  • A probe is passed into the lacrimal sac.
  • The sac and nasal mucosal incisions are drawn
  • the posterior mucosal flaps are sutured with the probe or catheter in place
  • The anterior mucosal flaps are sutured.
147
Q

Corneal Transplant (Keratoplasty)

A
  • Diseased cornea may be removed and replaced with donor cornea. Done if scars or opacity on cornea reduce or destroy vision. Cornea must be clear for vision.
  • Opacity may be from chemical burn, perforated corneal ulcers, herpes simplex virus, chlamydia, trauma, abrasion from contact lens or fingernails, or edema post cataract surgery
    • Keratoconus
148
Q

Types of grafts

A
  • Full thickness -common -whole cornea replaced (penetrating keratoplasty)–all 5 layers
  • Partial thickness -only top layer of cornea is replaced (lamellar keratoplasty)
149
Q

corneal transplant procedure

A
  • Bourne punch, a mechanical punch that uses disposable trephines on the donor tissue.
  • Stabilization instruments. Left to right, Flieringa rings, FlieringaLaGrand fixation forceps, Thornton fixation ring.
  • Excision of the host button by suction trephine.
  • A running suture is placed to secure the transplant.
150
Q

Donors-

A
  • special consent signed by next of kin and hosp. Rep. A certified eye bank technician may enucleate. Done under sterile conditions as if donor is still alive. Enucleated eyes must be in storage within 5 hours of enucleation. Preservatives for 72 hour storage or frozen for long term storage. Preferably used ASAP.
151
Q

Radial Keratotomy

A
  • reduces myopia (nearsightedness) by making multiple small radial incisions in cornea to 90% depth (did this before LASIK)
  • Potential complications:
    • A. Perforation of cornea
    • B. Permanent corneal scarring
    • C. Glaring vision
    • D. Injury to lens
    • E. Infection
152
Q

Glaucoma

A
  • abnormally increased intraocular pressure (cilliary body producing too much aqueous humor). If uncontrolled, it can lead to atrophy of optic nerve, hardening of the eyeball, and blindness
  • The pressure is normally balanced by:
    • A. Rate of secretion of aqueous humor
    • B. Resistance to flow through the narrow opening between lens and iris at the entrance to anterior chamber.
    • C. Resistance of resorption at trabeculated region of the iridocorneal region.
153
Q

Flow of Aqueous Humor

A

schelmms canal reabsorbes

154
Q

Diagnostic tests glaucoma

A
    1. Intraocular pressure measurements
      * A. Shiotz tonometer -measures corneal deformation produced by a given force.
      * B. Air Puff device -air blast flattens cornea and electronically measures time it takes for complete flattening
    1. Ophthalmoscopy -damage to optic cup (size and depth increase).
    1. Gonioscopy and transillumination -assesses anterior chamber depth.
155
Q

2 types of Glaucoma:

Narrow Angle (Closed Angle) and Wide Angle (Open Angle)

A
  • If angle is narrow, the iris may obstruct outflow of aqueous-painful and emergency (no cure just manage it). Open angle is the most common. It is a chronic type. May cause permanent damage before detected. The obstruction is not mechanical-it is physiological. Usually cannot filter aqueous.
156
Q

Trabeculectomy

A
  • A sponge with an antimetabolite is placed on the sclera
  • The sclera is drawn over the sponge
  • Irrigation.
  • Scleral flaps are created.
  • An incision is made into the anterior chamber
  • F, G, A fistula is created by the removal of a flap from the limbus
157
Q

Cataracts

A
  • an opacification of lens, its capsule or both. Light cannot pass through
  • Three classifications:
    • A. Congenital -present at birth. Can be caused by toxins, rubella, genetic defects, radiation.
    • B. Senile -occurs with aging. The nucleus and cortex enlarges as new fibers are formed. In nucleus, the old fibers become compressed and dehydrated.
    • C. Traumatic -lens opacification caused by foreign body injury to the lens, or blunt trauma.
158
Q

Two methods for cataract removal

A
  • A. Intracapsular -removal of lens within its capsule
  • B. Extracapsular -anterior portion of capsule is ruptured and removed with the lens, leaving the posterior capsule in place. Most common.
159
Q

Phacoemulsification

A
  • permits removal of lens thru smaller incision. Uses ultrasonic energy to fragment hardened lens and aspirate it. Handpiece is foot controlled. Capsule incised with cystotome, PE needle placed into anterior chamber, needle breaks up lens with vibrations. BSS is constantly flowing to keep sleeve cool. Cortex is polished with Irrig / aspir.
160
Q

Advantages of PE

A
  • A. Reduces recovery. Full activity in 1-2 days.
  • B. Smaller incision
  • C. Retains posterior capsule
  • D. Posterior capsule supports IOL
161
Q

Disadvantages of PE

A
  • A. Contraindicated for patients with corneal disease, dislocated lens, shallow anterior chamber, completely hardened lens, and it is difficult to dilate pupil.
  • B. Required special techniques = Dr’s have to learn how to use it. •
  • C. May injure cells from increased irrigation. Corneal cells sensitive to manipulation
  • D. Technical monitoring of equipment.
162
Q

ECCE with IOL

A
  • Extracapsular cataract extraction with intra ocular lens
163
Q

Orbital Procedures

A
  • Trauma -if eyeball is beyond repair, either an
    • eviseration (removal of contents of the eyeball) or
    • enucleation (removal of the eyeball) is done.
    • Exeneration is removal of the entire orbital contents including periosteum
164
Q

Strabismus

A
  • inability to direct both eyes at same object because of lack of coordination in extraocular muscles. TX: Prism glasses or Surgical.
  • Types of Repairs
    • Resection- removal of portion of muscle and anastomosis of both ends
    • Recession -severence of muscle at origin with reattachment more posteriorly
    • Myectomy
    • Tuck
165
Q

resection procedure

A
  • A, The sclera is incised.
  • B, A muscle hook is inserted to expose the insertion of the muscle.
  • C, With the muscle hook in place, the attachment is divided with Wescott scissors
  • D, Sutures are placed across the muscle attachment in its new location.
166
Q

Retinal Detachment

A
  • AKA “R. D .”AKA Detached Retina:
  • Separation of neural retinal layer from pigmented epithelium layer of retina. Resulted from neoplasms, infection, or, more commonly, injury and degeneration. DIABETES
167
Q

• Specific Reasons: for retinal detachment

A
  • 1) Normal Aging –results in atrophy of the vitreous body, causing traction on the retina.
  • 2) Aphakia –def –without a crystalline lens, ie Post Cataract extraction.
  • 3) High Myopes –Large globe, limited amt of retina, resulting in thinned out retina.
  • 4) Trauma –Sugar Ray Leonard.
  • 5) PDR –Proliferative Diabetic Retinopathy.
  • 6) Premature birth – high oxygen environment
168
Q

Signs and Symptoms Retinal Detachment

A
  • Light flashes
  • “Wavy” or “Watery vision”
  • Veil or obstructing vision
  • Shower of floaters that resemble spots, bugs or spider webs
  • Sudden decrease of vision
169
Q

Diabetic Retinopathy

A
  • def –A group of vascular disorders of the retina, caused by diabetes. The exact Mechanism is complex, but centers around Abnormal Blood Vessels
    • Background diabetic retinopathy –AKA Non-proliferative:
    • Proliferative diabetic retinopathy –PDR
170
Q

Four types of detachments

A
  • A. Retinal tear -caused by inflammatory response to trauma.
  • B. Quadrant detachment
  • C. Complete Detachment
  • D. PVR – proliferative vitreoretinopathy (recurrent retinal detachment)
171
Q

Vitrectomy

A
  • the removal of all vitreous humor. Under general anesthesia. For vitreal opacities, vitreal hemorrhage, and retinal detachments. Vitreous is removed to work on retina.
  • Types:
    • A. Posterior segment –via pars plana, the anterior attachment of retina. This area has no visual function, so nontraumatic. Used to incise opacified vitreous- old hemorrhage or bands of scar tissue to restore visual function.
    • B. Anterior –via limbus. To remove vitreous leakage into anterior chamber
172
Q

Vitreous will be replaced with aqueous humor eventually, but can be replaced with

A
  • BSS, Air, Expansion gas or silicone oil temporarily.
    • Air makes eye “balloon like” so retina lays flat against the eye. Body absorbs the air. The patient must remain with their face facing down (prone).
    • Expansion gas will expand as the body absorbs and prevents aqueous fluid from developing behind the tears. The patient must remain with their face facing down (prone).
    • Silicone oil is heavy, viscous oil that the body cannot absorb. Highly toxic and cannot stay in longer than six months. Patient cannot put face facing down as there is a danger the oil will leak into the posterior and anterior chamber .
173
Q

• Need for vitrectomy

A
  • Infusion line to maintain eyeball shape
  • Instrument to cut and aspirate vitreous
  • Light source
174
Q

Laser treatment -two types

A
  • Direct laser -inside eye.
    • Advantage = true laser directly on retina.
    • Disadvantage = with microscope and it is only a “straight shot”.
  • B. Indirect laser -external.
    • Advantage = can angle for peripheral retina.
    • Disadvantage = may hit more retinal than the exact spot needed.
175
Q

Scleral Buckle Procedure (for reccurrent retinal detachment)

A
  • A retinal tear at equator of glove at 1:30 o’clock position.
  • The surgeon visualizes the field and places the electrode beneath the retinal tear; a burn mark is made on sclera at the site of the retinal tear with the diathermy electrode.
  • A sponge is sutured in place over the treated site of the retinal tear.
  • A band and tire are used to encircle the eye.
  • A Watzke silicone sleeve is placed to secure the encircling band.
  • an incision is made in the sclera, and a fine incision is made in the choroids to allow subretinal fluid to drain.
176
Q

Cryotherapy

A
  • Used to freeze the retina to the choroid and cause adhesion formation
177
Q

General Information for eye case

A
  • Dilating drops begin 2 hours before surgery and given every 15 minutes.
  • Positioning
    • supine, eye bed
  • Anesthesia
    • retrobulbar block with spinal, heavily sedated
  • Prep
    • opthamalic bedadine
  • Draping
    • eye drape, U-drape, 1060 drape
  • Instruments
    • Mayo= plastic side for no lint, delicate instruments clean with water and foam
    • castro viejo needle holder
  • Hemostasis
    • bipolar eraser
  • mayfeild head frame
178
Q
A
179
Q

Mydriatics

A
  • For Mydriasis (dilates the pupil but permits forcusing
  • used for objective examination of the retina, testing of refraction, easier removal of lens
180
Q

Miotics

A
  • cholinergic
  • contricts pupil
181
Q

Viscoelastics

A
  • lubricant and support, maintains separation between tissues to protect the endothelium and maintain the anterior chamber intraocularly
182
Q

Irrigants

A

(Calanced Salt soluntion

keep cornea moist during surgery

183
Q
A

Barraquer Eye Speculum

184
Q
A

Castroviejo Caliper

185
Q
A

Castroviejo double ended cyclodialysis spatula

186
Q
A

Kelman-McPherson sngled tying forceps

187
Q
A

Castroviejo fixation forceps

188
Q
A

Castroviejo corneal section scissors

189
Q
A

Castroviejo Needle Holder

190
Q
A

Bishop-Harmon Irrigation Cannula

191
Q
A

Air injection cannula

192
Q
A

Bowman lacrimal probe set

193
Q
A

Jameson Muscle Hook

194
Q
A

Lambert Chalazion Forcep

195
Q
A

Barraquer iris spatula

196
Q
A

Utrata capsulorrhexis forceps

197
Q
A

Wells enucleation spoon

198
Q
A

Wescott tenotomy scissors

199
Q
A

Bishop-Harmon forceps

Surgical Procedures II (5 decks)

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