Boyle Davis Mouth Gag

This instrument is part of the tonsillectomy set.

Mouth gags are used to keep the patient’s mouth open during oral surgery, leaving both hands of the surgeon free to operate.

The Boyle Davis mouth gag consists of the Davis gag, a frame that serves to hold the mouth open and the Boyle tongue depressor to hold the tongue down. The tongue depressor comes in several sizes, from pediatric to adult. The instrument is assembled by sliding the tongue blade into the frame. The mouth gag is held in position using the Draffin bipod stand.

This is a picture of the Draffin's bipod stand. These two rods are used to hold the mouth gag.

Uses

Used in oral and oropharyngeal surgeries.

• Adenoidectomy
• Tonsillectomy
• UPPP and other procedures on the soft palate
• Procedures on the hard palate like cyst or tumour excision

More information

• It cannot be used to perform procedures on the tongue as it is completely held down by the tongue blade.
• This instrument can cause injury to the lips and teeth. Care must be taken while applying the mouth gag to avoid getting the lips caught in it.
• Opening the mouth excessively with the gag can cause dislocation of the temporomandibular joint.

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Tonsillectomy Instruments – Dissection Tonsillectomy Set

The dissection method of tonsillectomy requires the use of several instruments. Here is a comprehensive list of instruments in the tonsillectomy set. Read the individual posts for photos, complete descriptions and the uses of each instrument.

Boyle Davis mouth gag – This instrument gives access to the tonsils and keeps the mouth open during surgery.

Scalpel – This is used to make the incision on the medial edge of the anterior pillar. A no.15 blade or the sickle-shaped no.12 blade may be used. Some surgeons also use the tooth on toothed forceps to make the incision.

Denis Browne tonsil holding forceps – These forceps are used to grasp and hold the tonsils during surgery.

Gwynne Evans tonsillar dissector – This instrument is used to dissect the tonsil from its bed.

Eve’s tonsillar snare – This instrument is used to cut and crush the pedicle of the tonsil in order to remove the last of its attachments.

Waugh’s toothed forceps – This pair of long forceps is used while packing the tonsillar fossa.

Birkett’s tonsillar first artery forceps – These forceps are used to catch bleeders in the tonsillar fossa after tonsillectomy.

Wilson’s or Negus second artery forceps – These forceps are used while applying ligatures to bleeding points in the tonsillar fossa after tonsillectomy.

Mollison’s anterior pillar retractor – This instrument is used to retract the anterior pillar to examine the tonsillar fossa for bleeders after the removal of the tonsils.

Yankeur’s suction tip – This tip is ideal for suction blood and pharyngeal secretions during tonsillectomy.

Read the individual posts for complete details about each instrument.

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Tonsillar Second Artery Forceps

This instrument is used while applying ligatures to bleeding points in the tonsillar fossa following tonsillectomy.

Identification

 This instrument is the Negus second artery forceps. Notice how its tip is curved like a hook.

This is another variety of the same instrument – this is the Wilson second artery forceps.

Both its shaft and tip are bent at obtuse angles.

How the instrument is used

When a bleeding spot is observed in the tonsillar fossa following tonsillectomy, it is first caught using the tip of a first artery forceps. The bent tip of the second artery forceps is then applied below the tip of the first artery so that some of the surrounding tissue can be held as well. The ligature is then applied below the second artery.

More information

Ligatures applied in the tonsillar fossa don’t have to be removed, they slough away by salivary action.

Second artery forceps are used along with the first artery forceps and the anterior pillar retractor while ligating bleeding points in the tonsillar fossa.

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Birkett’s Tonsillar First Artery Forceps

This instrument is part of the tonsillectomy set and is used while applying ligatures to control bleeding.

Identification

The tonsillar first artery forceps are long, straight artery forceps with a ratchet for locking.

How the first artery forceps are used

Following tonsillectomy, the fossa is inspected for bleeding points. The tip of the first artery forceps is used to ‘catch’ the bleeder. The second artery forceps are then used before applying ligatures to the bleeding point to stop hemorrhage.

The first artery is also used to pack the tonsillar fossa with gauze immediately after tonsillectomy and to gently swab the fossa while inspecting it for bleeding points.

It can also be used to remove clots present in the fossa.

More information

• The other method to stop bleeding from the tonsillar fossa is to use electrocautery.
• While applying ligatures, the first artery is used along with the anterior pillar retractor and the second artery forceps.
• Clots present in the tonsillar fossa can prevent hemostasis by coming in the way of muscular contraction and should be removed.

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Mollison’s Anterior Pillar Retractor

The anterior pillar retractor is used in tonsillectomy operations.

Identification

This is a long and thin instrument one end of which is flattened out like a blade. The other end is wide and its edge is curved.

This is end may be hooked around the edge of the anterior pillar to pull it laterally after tonsillectomy.

The tonsillar dissector is a similar looking instrument in the tonsillectomy set. To differentiate the two, closely observe the ends. One end of the dissector is serrated like a comb.

How to use the pillar retractor

The curved edge is hooked around the free edge of the anterior pillar to retract it laterally. This gives a very good view of the entire tonsillar fossa which can be inspected for remnants and bleeding points after the removal of tonsils.

More information

• Reactionary bleeding is hemorrhage that occurs in the postoperative period within 24 hours.
• It usually occurs due to slipping of ligatures.

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Gwynne Evans Tonsillar Dissector

This instrument is used in the dissection method of tonsillectomy.

The tonsillar dissector is a long and thin instrument that is used to separate the tonsil from its bed in the dissection method of tonsillectomy. While one end is flattened out like a blade, the other end is serrated.

Uses

• Tonsillectomy – The flat end is used for sharp dissection while the serrated end is used to release the connective tissue holding the tonsil to its bed.
• The serrated end is also useful in other surgeries like the removal of cysts when connective tissue has to be separated from the cyst wall.
• The instrument is also useful in separating periosteum from bone in some surgeries.

Differentiating it from other instruments:

The Freer’s elevator

This is a long, thin instrument used in septal surgeries. Both its ends are flattened out like blades. Also, it is smaller and thinner compared to the tonsil dissector.

Pillar retractor

This is an instrument that looks very similar to the tonsillar dissector. Unlike the Freer’s elevator which is noticeably small, this instrument is similar to the tonsil dissector in size and bulk. The trick is to hold the instrument and examine its ends. One end is flattened and blade like but the other end is wide and the tip is bent to form a hook. Read more about the anterior pillar retractor to learn how to identify it and to look at pictures.

More information:

• Other instruments that can be used for tonsillar dissection are Waugh’s toothed forceps and sharp dissecting scissors.
• It is important to carry out dissection in the exact plane between the tonsil and its bed – digging either into the fossa or the tonsil can cause a lot of bleeding.

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Denis Browne Tonsil Holding Forceps

This instrument is used in tonsillectomy operations.

Uses

Tonsil holding forceps are used to hold the tonsil during tonsillectomy. The tonsil is grasped gently and then pulled medially. This step helps hold the tonsil away from its bed to facilitate dissection and prevent injury to structures in the bed of the tonsil.

Identifying the instrument

Tonsil holding forceps are long and sturdy with the shaft bent at an angle to the handle. The tips are cup-shaped with holes.

The instrument is very similar to the Luc’s forceps used in septal surgeries. To differentiate the two, examine the tips of the forceps. The edges of the tips are smooth in tonsil holding forceps, their job is to just hold tissue, whereas the edges of the tips are sharper in the case of Luc’s forceps because they have to do some cutting.

Also, the cup-shaped tip of the upper arm fits into the tip of the lower arm in the case of tonsil holding forceps.

Additional information

• The tonsils are located in the tonsillar fossa bounded anteriorly by the anterior pillar or the palatoglossal fold and posteriorly by the posterior pillar or the palatopharyngeal fold.
• The bed of the tonsil is made of the superior constrictor muscle which is separated from the tonsil by connective tissue that forms the plane of dissection in tonsillectomy.
• The carotid artery is located about 2.5cm deep to the bed of the tonsil.

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Eve’s Tonsillar Snare

This instrument is part of the tonsillectomy set and is used in the step of removing the dissected tonsil from its final attachment to the fossa.

Identification of the instrument

This is an easy instrument to identify. It consists of a long, thin, hollow tube with a stainless steel wire loop at one end and three large rings at the other. These three rings allow the instrument to be operated using three fingers.

How the tonsillar snare is used

The instrument is held by inserting the forefinger and the middle finger into two rings on either side of the snare. The thumb is placed in the single ring at the back. This ring is actually located at the end of the plunger. Pulling the plunger with the thumb draws out the wire loop while it can be pulled back in by pressing the plunger with the thumb.

The wire loop is first threaded over the Denis Browne tonsil holding forceps. The dissected tonsil is then held with the forceps and the wire loop moved over it until it surrounds the pedicle of the tonsil. The thumb is then pressed down to draw back the loop. The pedicle of the tonsil is both cut and crushed by this movement. Cutting and crushing the pedicle rather than just cutting it helps reduce hemorrhage.

More information:

• Earlier, snares were also used to remove nasal and aural polyps, too. The Glegg’s (avulsion) snare was used to avulse nasal polyps, while the Krause aural snare was used to remove aural polyps. These instruments are not used anymore.
• In the absence of a tonsillar snare, the pedicle can be clamped with long, curved artery forceps, cut and tied with silk.
• After the tonsil is snared out, the raw tonsillar fossa is immediately packed with gauze to achieve hemostasis.

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Lack's Tongue Depressor

This is a very commonly used OPD instrument.

It has two blades at right angles to each other. One of them is slightly wider than the other and is completely flat. This is the part of the tongue depressor that is inserted into the oral cavity. The other blade is narrower and has a slight curve at its free end, like a handle. This is the part of the instrument that is held in your hand.

Uses of the tongue depressor:

Examination of the oral cavity – vestibule, buccal mucosa, gums, floor of the mouth

Examination of the oropharynx and posterior pharyngeal wall

Used in posterior rhinoscopy, along with the postnasal mirror

For the ‘cold spatula test’ –  to assess (approximately) the nasal airway/ patency in the OPD

To perform minor procedures in the oral cavity

To take a throat swab or a swab from the tonsil

How to use the tongue depressor:

Hold the instrument by the narrower blade that acts as a handle.

Insert the other blade into the oral cavity.

First retract the cheek so you can examine the vestibule, buccal mucosa and gums and repeat the same on the other side.

Then place the blade flatly on the dorsum of the tongue and press it down – this will allow you to examine the palate, tonsillar pillars, the tonsils and the posterior pharyngeal wall.

Take care to depress only the anterior two-thirds of the tongue with this instrument. Touching the posterior third of the tongue will elicit the gag reflex.

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Indirect Laryngoscopy Mirror

This mirror is used to examine the larynx in the outpatient using a procedure called indirect laryngoscopy.

How indirect laryngoscopy is done:
 

• The indirect laryngoscopy mirror is warmed to avoid fogging on it.
• The patient is asked to protrude his/her tongue which is then held with a piece of guaze.
• The patient is directed to breathe through his/her mouth.
• The warmed indirect laryngoscopy mirror is then introduced into the oral cavity with the mirror facing downwards. (Check its temperature by touching the back of your hand with it, it should not be hot.)
• The mirror is brought to rest against the uvula but do not touch the posterior pharyngeal wall to avoid setting off the gag reflex.
• Once the laryngeal inlet is visualized, the patient is asked to say ‘eee’ to check the movement of the vocal cords.

Structures seen on indirect laryngoscopy (in order):

• Base of the tongue (posterior one-third of the tongue)
• Vallecula
• Median and lateral glossoepiglottic folds
• Epiglottis
• Pharyngoepiglottic folds
• Aryepiglottic folds
• Arytenoids
• False vocal cords
• True vocal cords
• Tracheal rings

Indications for indirect laryngoscopy:

• Examination of the larynx in cases of change in voice
• Examination for dysphagia
• To look for vocal cord mobility prior to thyroid surgery
• To look for the primary in cases of neck metastases

The shaft of the indirect laryngoscopy mirror is straight, a feature which helps differentiate it from the posterior rhinoscopy mirror which has a bent shaft.

More information:

• The mirror is available in 5 sizes, the smallest is 1 and the largest 5.
• Indirect laryngoscopy was first performed by Manuel Garcia, a singer.
• Using flexible fibreoptic laryngoscopy is another method of examining the larynx in the OPD.(Read examination of the larynx to learn what other methods can be used to visualize the larynx.)

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