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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Jobson-Horne Ear Probe

This is a commonly used OPD instrument and is also called the wax hook or ring curette.

Uses:

Ear wax removal

Removal of foreign body from the ear

Removal of otomycotic debris or discharge from the external auditory canal

Probing of aural polyp or other mass in the ear canal

Probing of nasal masses and checking their sensitivity to touch

If you look closely, you will find that one end of the probe is shaped like a ring. This end may be used to hook out wax or foreign bodies from the ear canal.

The other end of the instrument is sharp and serrated. An ear wick can be fashioned out of this end by rolling cotton on to it and used to mop ear discharge.

More Information:

• If wax in the ear canal is impacted, it is better to first soften it with wax-softening or dissolving agents and then attempt to remove it.
• Wax in the ear canal can also be removed by syringing using an aural syringe or by using suction apparatus under microscopic visualization.

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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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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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Tuning Forks

In ENT, tuning forks are used to clinically test hearing and identify the type of hearing loss.

The parts of a tuning fork are:

• Base plate or footplate
• Shaft
• Prongs that vibrate producing sound

If you look at the shaft or the footplate closely, you will find it carries a number - this is the frequency at which the tuning fork vibrates and is denoted in Hertz (Hz). The commonly used tuning forks to test hearing are 256 Hz, 512 Hz and 1024 Hz. These frequencies correspond to the speech frequencies. Tuning forks of lower frequencies (like 128 Hz) produce vibrations that are felt more than they are heard, while those of higher frequencies produce more overtones.

More information:

• Tests done with these tuning forks include Rinne's, Weber's and the absolute bone conduction test.
• Other tests, not routinely performed, are the Bing's test, Stenger's, Gelle's and Chimani Moos test.
• If you have to perform these tests with a single tuning fork, pick the 512 Hz.
• To set the tuning fork into vibration, always strike it against a firm but yielding surface like your elbow
   and not hard surfaces like table tops.

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Aural Syringe

This instrument is the metallic aural syringe, an instrument used for syringing of the ear, an OPD procedure.


Indications for ear syringing:

• Wax removal
• Foreign body removal
• Removal of otomycotic debris

The syringe has a nozzle for insertion into the external auditory canal. Water at body temperature is loaded into the syringe. The syringe is held by inserting fingers into the rings at the back. The third ring is on the piston that forces the water out when pushed.


More Information:

• Syringing should be avoided in case of perforated tympanic membrane.
• Aural syringing can result in complications like trauma to the external auditory canal and perforation of the tympanic membrane.
• Other methods of wax and foreign body removal include manual removal using the Jobson-Horne wax hook, suction and removal under microscope.

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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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