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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St Clair Thomson Adenoid Curette

The adenoid curette is used in adenoidectomy operations.

The instrument has a strong handle, a shaft and a curette at the tip. The curette itself is a curved, square window that allows for the tissue to engage in it.

An adenoid curette with cage comes with a detachable guard that has teeth to hold the removed tissue.

How the adenoid curette is used

For the adenoidectomy operation, the patient lies supine in the neutral position. The mouth is held open with a mouth gag. The curette is held at the handle like a dagger. The curette is then introduced into the oral cavity, all the way above and behind the soft palate. The adenoid tissue is caught in the curette and removed with a smooth, shaving movement.

Adenoidectomy was earlier performed as a blind procedure. A nasal endoscope can now be used to visualize the procedure.

More information

• Endoscopic adenoidectomy achieves better results and lesser complications as the procedure is performed under visualization.
• Endoscopic adenoidectomy can be performed using endoscopic instruments and/or microdebrider.
• Hypertrophied adenoids cause nasal obstruction, nasal discharge and predispose to ear conditions like otitis media and otitis media with effusion.

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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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Eustachian Tube Catheter

The Eustachian catheter is a long, thin metal instrument mainly used to test Eustachian tube patency but with a few other uses as well.

It is actually a curved, metal cannula, measuring about 5 inches in length. Its tip is curved gently downwards. The other end bears a small metal ring in the direction of the curve. This ring serves as a guide to the direction of the curve once the tip is inserted into the nose.

Uses:

• Eustachian tube catheterization
• Nasal foreign body removal – The Eustachian catheter is sometimes used for removal of foreign bodies from the nose. It is a sturdy instrument whose curved tip can be used to nudge and maneuver foreign bodies lodged in the nasal cavity.

How Eustachian tube catheterization is done

This procedure is more than a century old and was earlier routinely done to check patency of the Eustachian tube.

• The tip of the catheter is inserted into the nose and passed along the floor of the nasal cavity till it touches the posterior pharyngeal wall. The tip is now in the nasopharynx.
• It is then rotated 90° medially and drawn forward till it meets resistance. The tip is now touching the posterior free end of the nasal septum.
• At this point, the tip is rotated 180° laterally so that it enters the opening of the Eustachian tube in the lateral wall.
• A Politzer bag is attached to the other end of the catheter. Air pushed from it can be heard rushing into the ear if the Eustachian tube is patent.

The medial and lateral rotations that appear to complicate the procedure were actually designed to avoid the tubal elevation located behind the tubal opening since the tip cannot be seen once inserted into the nose. The original procedure was a blind one, with only the metal ring to indicate the direction of the catheter’s tip. But the procedure can also be done under endoscopic guidance.

The important thing to remember is that the method only tests patency of the Eustachian tube and does not reflect on its function.

Other methods to test Eustachian tube patency

• Seigelization (or pneumatic otoscopy)
• Valsalva maneuver
• Politzerisation
• Toynbee’s test

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Trousseau’s Tracheal Dilator

This instrument is a part of the tracheostomy set. It should be available not only in the OR but also in the emergency/casualty.

Uses of the tracheal dilator

It is basically used to widen the tracheal opening while inserting a tracheostomy tube

• Peroperatively during tracheostomy
• During a tube change

It is especially useful should the tube accidentally come off in the early post op period, when the track is still not well formed.

Identifying the instrument

It looks like a pair of regular artery forceps except that

• Its tip is bent at almost right angles to the rest of the instrument
• There is no lock or clasp
• The tip is smooth and rounded unlike the sharp, dissecting tip of the artery forceps

Note how the tip of the dilator is bent at right angles to the rest of the body. This helps reach the tracheal opening located at a depth in the neck.

Notice how bringing your fingers together actually opens the tracheal dilator. The instrument has a spring action to keep it closed; the prongs will remain open only as long as you hold them apart.

How to use the tracheal dilator

The instrument is held by inserting your thumb and index fingers into the rings provided. When using regular artery or Allis forceps, if you bring your thumb and index fingers together, the prongs of the instrument also move inwards and close. But with the tracheal dilator, when you bring your two fingers together, the prongs at the tip of the instrument move away from each other.

So hold the instrument, insert the tip into the tracheal stoma and bring your fingers together. This will help you widen the tracheal opening so you can slide in the tracheostomy tube.

 

More information

• Stay sutures may be placed on either side of the tracheal opening. Pulling on these sutures will help to hold open the stoma and to pull it up to the level of the skin, facilitating tube insertion or change.
• Structures to be divided before the trachea can be reached:
• Skin
• Subcutaneous tissue
• Strap muscles
• Isthmus of the thyroid
• Pretracheal fascia
• How to prevent accidental displacement of the tracheotomy tube before the track is formed
• Correct placement of the tube
• Firmly securing the tube – the tube may even be secured with sutures

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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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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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