Killian’s Nasal Gouge

This instrument is part of the septoplasty set.

The Killian’s nasal gouge is bayonet shaped – that is, its shaft is bent so that the tip lies on a higher plane than the handle. This feature ensures that the hand holding the instrument does not obstruct vision and the surgeon can visualize the tip of the instrument inside the nasal cavity.

The tip of the instrument is V-shaped and very sharp. This feature helps remove spurs and sharp projections during septal surgeries.

This is a mallet (or hammer) used along with the gouge.

Uses

The instrument is used in septoplasty to remove spurs. It is especially useful to remove a deviated maxillary crest.

The wedge-shaped tip is placed at the beginning of the spur or bony projection in the septum. With the instrument in place, its handle is tapped gently with the mallet as the gouge cuts through the bony projection which is then removed with nasal dressing forceps.

More information

• Spurs are horizontal projections in the septum often formed at bony cartilaginous junctions that may cause nasal obstruction.
• The maxillary crest lies at the floor of the nasal cavity. It is sometimes deviated resulting in a large spur near the floor of the nasal cavity.
• Another type of gouge in ENT is the mastoid gouge. Before the introduction of the surgical drill, the mastoid gouge and hammer were used to perform mastoidectomy.

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Freer’s Elevator

This instrument is an important part of the septoplasty set.

Uses of the Freer’s elevator:

• Elevation of mucoperichondrial/mucoperiosteal flaps in septoplasty or SMR
• Separation of the septal cartilage from bone during septoplasty
• To perform uncinectomy during endoscopic sinus surgery
• For mucoperiosteal flap elevation in endonasal DCR

Identifying the septal elevator

This is a thin and long instrument with small flattened blades at either end. Most elevators are straight at one end and slightly curved at the other.

This is a close up of one end of the septal elevator.

Differentiating it from the tonsillar dissector

The tonsillar dissector is also a long and thin instrument, one end of which looks very much like the Freer’s elevator. Here’s how to tell the two instruments apart.

• The tonsillar dissector is slightly longer and stouter than the septal elevator.
• It has a blade on one end that is similar to the ones on the Freer’s elevator, but slightly larger.
• But the other end is bent and serrated with a comb like appearance.

How to use the Freer’s elevator

The straight end may be used for elevation of flaps. The curved end may be used in septoplasty to separate the quadrilateral cartilage from bone and elevate the mucoperiosteal flap on the opposite side.

The curved end may also be used to make an incision at the attachment of the uncinate process to the lateral wall of the nose during uncinectomy. (This is one method of performing uncinectomy, there are several others.) Both ends of the instrument are usually sharp, a feature that helps flap elevation and sharp dissection. 

If you look closely at the blade, you will find that one surface is flat and the other is gently curved. During flap elevation in septoplasty, make sure the flat surface and the sharp end rest on the cartilage or bone, while the smooth, curved side faces the flap. This will help you apply pressure on the septum without tearing the flap.

More information:

The elevator is used even in endoscopic septoplasty.

Modifications of the elevator with provision for suction are available. Bleeding during flap elevation is common and this instrument helps provide a clear field.

This instrument is also handy in any procedure that involves dissecting soft tissue off cartilage or bone.

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Tilley's Nasal Dressing Forceps

This nasal instrument has important functions in both the OPD and the operating room. It is also called the packing forceps or dressing forceps. No nasal surgery set is complete without these forceps.

Uses of the nasal dressing forceps:

To perform anterior nasal packing

To remove foreign bodies, crusts or packs from the nose

To pack the nose with gauze strips during nasal surgeries or sinus surgeries

To remove cartilage and bone pieces during septoplasty or SMR

Identifying the nasal packing forceps:

Like most nasal instruments, these forceps are bent at an angle so the hand grasping the instrument doesn't obstruct the vision of the examiner. The blades are long and thin so they can be easily inserted into the nasal cavities.

Differentiating nasal and aural forceps:

Both instruments are very similar to look at. The difference is in the tip. Aural forceps have tips that are triangular while the tip of the nasal forceps is straight and serrated. The serrations give grip to the instrument and help grasp the various objects mentioned above.

 

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Nasal Foreign Body Hook

This is an instrument used in the outpatient to remove foreign bodies from the nose.

Nasal foreign bodies are common in children and in mentally retarded or disturbed individuals. The usual foreign bodies seen are small objects like beads, seeds, chalk piece or even stones.

Foreign bodies in the nose cause symptoms like nasal obstruction and discharge. Children often present with a history of unilateral, foul-smelling and/or blood stained nasal discharge. Anterior rhinoscopy may reveal the foreign body, covered with slough or discharge. Long standing foreign bodies in the nose sometimes get covered by deposits of salts and slough and become rhinoliths.

How is the foreign body removed

It is important to pass the tip of the instrument over and beyond where the object is lodged in the nose so that it can be hooked and drawn forward along the floor of the nasal cavity.

If you look closely, you will find that one end of the foreign body hook is shaped like a ring.

The other end is a curette, shaped like a spoon.

Differentiating it from the Jobson Horne wax hook:

The Jobson Horne wax hook is a similar looking instrument used to remove wax and foreign bodies from the ear. Here's how to tell the nasal foreign body hook and the wax hook apart.

• The nasal hook is shorter and stouter than the ear hook.
• One end of both instruments is ring shaped, but the ring on the wax hook is smaller and more delicate.
• The other end of the nasal hook is spoon-shaped while it is thin and sharp in the case of the wax hook.

Other methods of removing nasal foreign bodies:

• Earlier, an instrument called the Eustachian catheter, one end of which is slightly bent, was used to hook out the foreign body.
• Using the endoscope and endoscopic instruments.
• In very small and uncooperative children, the foreign body is better removed under general anesthesia.

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Nasal Speculum - Thudichum's

The Thudichum’s nasal speculum is an instrument routinely used in the outpatient to examine the nose.

The instrument has two flanges that can be inserted into the nostril during anterior rhinoscopy. The flanges widen to open up the nasal cavity, offering a better view of the structures inside the nose.

Uses of the Thudichum’s nasal speculum:

• In anterior rhinoscopy
• Foreign body removal from the nose
• Peroperatively, for nasal packing
• In septal surgeries (septoplasty and SMR) while making the incision

How to use the Thudicum’s nasal speculum:

First, hold the instrument at its bend with your thumb and index finger.

Then, place your middle and ring fingers either side of the limbs of the speculum. Bringing these fingers close to each other will also bring the flanges of the speculum close together. Insert the instrument into the nostril in this position. Moving your middle and ring fingers apart will widen the flanges of the speculum, opening up the nasal cavity in the process.

More Information:

• Insert the speculum fully closed into the nasal cavity, but keep the flanges slightly open while drawing the speculum out to avoid pulling any vibrissae!
• Practice using the Thudicum’s speculum during your clinical posting, the method described above is the optimal way to best visualize the nasal cavity.
• Structures seen on anterior rhinoscopy:

            - Nasal septum

            - Lateral wall of the nose including the turbinates and the meati

            - Floor of the nasal cavity

• Do not use the nasal speculum to examine the vestibule. Just lift up the tip of the nose with your finger to look at the vestibule of the nose, using the speculum will only obscure it from your vision.

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Posterior Rhinoscopy Mirror

This instrument is the St. Clair Thompson post-nasal or posterior rhinoscopy mirror.

Uses:

Examination of the post nasal space by a procedure called posterior rhinoscopy, an out-patient procedure.
The mirror is warmed and introduced into the oral cavity while the tongue is depressed with a tongue depressor. The mirror is turned upwards in order to examine the post nasal space.

The shaft of the instrument is bent to achieve a bayonet shape, a feature that helps differentiate it from the indirect laryngoscopy mirror. The mirror is available in 5 sizes.

More Information:

• Posterior rhinoscopy is done to look for lesions in the post nasal space - for example, adenoids, tumours of the nasopharynx, etc.
• Diagnostic nasal endoscopy is the best method to examine this region.
• In small children who may be uncooperative for posterior rhinoscopy or nasal endoscopy, X-ray of the skull, lateral view, may be used to rule out adenoids.

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