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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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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Killian’s Nasal Speculum

This is one variety of nasal speculum and is used for both nasal examination and surgery.

It comes in several sizes, from small to long-bladed. A screw in the handle can be tightened to hold the blades of the speculum in the open position. This gives the speculum its self-retaining feature, very useful during septal surgery.

Unlike the Thudichum’s nasal speculum, this instrument is much easier to handle. The blades are attached to handles which can be used to open and close the speculum.

Uses

The Killian’s nasal speculum is used in:

•  Anterior rhinoscopy
• Anterior nasal packing
• Septoplasty
• Polypectomy
• Nasal foreign body, rhinolith removal
• Turbinate reduction surgeries

The speculum is particularly helpful in septoplasty. When the mucoperichondrial flap is being raised, the blades of the speculum can be used to lift the flap to provide access and vision. Later, when the mucoperiosteum has been elevated on both sides, the instrument can be positioned within the flaps with the blades on either side of the bony septum. The self-retaining feature of the instrument helps free both hands for bone removal.

More information

• In septoplasty, the mucoperichondrial flap is only raised on one side of the septal cartilage, whereas in SMR it is raised on both sides of the septum.
• Tearing the mucoperichondrial flaps in corresponding places on both sides of the septum can result in a septal perforation postoperatively.
• A septal hematoma occurs when blood collects between the septal cartilage and its mucoperichondrium.

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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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