ENT Procedures Jason Fowler, MPAS, PA-C Jose C. Mercado, MMS, PA-C April 26-28, 2013 New York-Presbyterian Hospital/Weill Cornell Medical Center.

ENT ProceduresJason Fowler, MPAS, PA-C

Jose C. Mercado, MMS, PA-C

April 26-28, 2013New York-Presbyterian Hospital/Weill Cornell

Medical Center

ENT Procedures Workshop

Basic instruction

Clear demonstration

Hands-on doing!

Removal Foreign Body (Nose)

Control Anterior Epistaxis

Control Posterior Epistaxis Fine Needle Aspiration

Peritonsillar Abscess Tracheostomy Care

Introduction

There are multiple methods and techniques available to successfully complete all the

topics presented in this workshop. Some are based on patient request, available

equipment or supervising physician’s preference.

The goal of this workshop is to correctly demonstrate the most common methods and give participants time for hands on

training.

ENT Procedures WorkshopLearning Objectives

• Discuss indications for and practice removal nasal foreign body.

• Discuss indications for and practice control anterior epistaxis.

• Discuss indications for and practice control posterior epistaxis.

• Discuss indications for and practice fine needle aspiration.• Discuss indications for and practice peritonsillar abscess

drainage.• Discuss indications for tracheostomy and practice

tracheostomy care.

• Purulent unilateral nasal discharge, especially in children

• Usually lodge on the floor of anterior or middle third

Figure. A: Fiberoptic nasal endoscopy shows the mass in the left anterior nasal cavity.

B: Coronal CT shows the area of attenuation in the left inferior turbinate.

C: Photograph shows the broken mass. D: Following removal of the mass, the

passageway is clear.


Mercado, JC, Goldberg SG, Recurrent purulent rhinorrhea in an otherwise healthy woman Ear Nose Throat J. 2004 Jun;83(6):381-2


Good visualization: headlamp & nasal speculum

Alligator forceps should be used to remove cloth, cotton, or paper

Other hard FB are more easily grasped using bayonet forceps or Kelly clamps, or they may be rolled out by getting behind it using an ear curette, single skin hook, or right angle ear hook

Practice mannequins available to practice

removal of nasal foreign bodies technique.



Control anterior epistaxis in office.

Apply direct manual pressure for at least 10

minutes

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Anterior vs PosteriorEpistaxis

Kiesslebach’s Plexus or Little’s Area is most common site of anterior nosebleeds.Woodruff’s Plexus is most

common site for posterior nose bleeds and may represent a lesion.

Sphenopalatine artery is generally the source of severe posterior nosebleeds.

Posterior more difficult to control will be discussed in Advanced ENT Procedures

Workshop.

Etiology of Epistaxis

Local

Trauma /Nose picking or blowing / surgery

Dry air / Irritants

Topical medications (steroids)

Foreign body

Tumor

Systemic

Bleeding disorders

Hereditary hemorrhagic telangiectasia

Drugs (anticoagulants)

Hypertension

Direct Manual Pressure

NO YESNO

Mercado 2011 ©Mercado 2011 © Mercado 2011 ©


Spray or apply topical anesthetic with decongestant.

Reapply direct manual pressure an additional 10 minutes.

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Once bleeding has subsided, identify

site of nosebleed.

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Control bleeding with silver nitrate cauterization. (start from outside in)

Caution bilateral cauterization as may result in septal perforation.

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Lubricate naris with Vaseline or Neosporin ointment.

Let sit for 10-15 minutes to ensure hemostasis is achieved.

Keep cotton in nares for at least 1 hour to prevent staining.

Avoid sneezing, forceful nose blowing, nose picking, etc.

Follow up 2 weeks as re-cauterization may be necessary.

Post chemical cauterization stain day 1

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Post chemical cauterization stain day 4

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Anterior Nasal Packing

Nasal packing• Absorbable gelfoam• Vasaline guaze• Nasal tampon• Anterior packing

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Nasal packing• Vaseline gauze – is

inserted along floor of naris to form a tight seal.

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Nasal packing• Nasal tampon –

expands in nasal cavity to form a tight seal.

• Do not allow packing to moisten until in position.

• Removal may cause re-bleeding.

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Anterior Nasal Tampon

• Insert nasal tampon horizontally.

• Lubricate with Neosporin but DO NOT moisten!

• Secure ties to cheek.

Practice mannequins available to practice anterior nasal packing

technique.

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Anterior nasal packing – Easy to insert and

remove due to self-lubricating hydrocolloid fabric and ultra-low profile.

– Packing quickly conforms to nasal anatomy and provides gentle and even compression to areas of epistaxis.

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• Soak dressing to hydrate Gel Knit hydrocolloid fabric in sterile water for 30 seconds.

• Insert Rapid Rhino horizontally.

• Inflate balloon only with air.

• Tape pilot cuff to side of face.

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How NOT to pack a nose!!!

Control Posterior Epistaxis

Anterior vs PosteriorEpistaxis

Kiesslebach’s Plexus or Little’s Area is most common site of anterior nosebleeds.Woodruff’s Plexus is most common site for posterior nose

bleeds and may represent a lesion. Sphenopalatine artery is generally the source of severe

posterior nosebleeds.

Posterior tend to be more difficult to control and may suggest an underlying etiology.

Etiology of Epistaxis

Local

Trauma (Nose picking or blowing)

Dry air / Irritants

Topical medications (steroids)

Foreign body

Tumor / polyp

Surgery

Systemic

Hypertension

Coagulopathies

Hereditary hemorrhagic telangiectasia

Drugs (anticoagulants)

Control Posterior Epistaxis• Control Hypertension• Identify Coagulopathy –Treat with FFP,

transfusions, etc– PT, PTT, INR

• Coumadin toxicity - Vitamin K• Posterior Packing• Endoscopic Cauterization• Arterial Embolization (Interventional Radiology)

Posterior Nasal Packing

• Topical anesthetic & decongestant

• Posterior nasal packing – Foley catheter– Double balloon

device

Rapid Rhino® 900 for Posterior Epistaxis

1. Thoroughly soak in sterile water for 30 seconds.

2. Insert Rapid Rhino into the patient’s nostril parallel to the septal floor, or following along the superior aspect of the hard palate, until the blue indicator ring is inside the opening of the nostril.

3. Using a 20 cc syringe, slowly inflate the posterior (green stripe) balloon first with air only inside the patient’s nose.

1 2 3

4 5 6

4. Inflate second balloon with air.

5. Allow the patient to sit for 15-20 minutes prior to discharge. Swelling in the nasal anatomy will reduce and the balloons may need to be inflated more to avoid movement of the device. Don’t forget prophylaxis antibiotics!

6. To remove packing, deflate balloons 24-72 hours later.

Rapid Rhino® 900 for Posterior Epistaxis

Additional Treatments

Arterial EmbolizationKoh E et al. AJR 2000;174:845-851

http://www.ajronline.org/content/174/3/845.fullhttp://www.ghorayeb.com/EpistaxisPosteriorEndoscopicView.html

Endoscopic CauterizationB. Ghorayeb, MD

Control Posterior Epistaxis

Practice mannequins available to practice

posterior nasal packing technique.

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Fine Needle Aspiration

Site Selection

Common sites include thyroid and parotid glands as well as lymph nodes.

Mercado 2011 © Mercado 2011 © Mercado 2011 ©

Anesthesia

• For superficial aspirates, clean technique suffices for cleansing of the skin surface.

• Local anesthetic may or may not be used. If more than two or three attempts are anticipated, this is recommended.

• However, be certain not to contaminate the lesion with a large volume of anesthetic.

• Also, make attempts not to directly interfere with the ability to palpate and localize the lesion.

• For deep aspirates, sterile technique is required for cleansing of the skin and local anesthetic is usually required.

Fine Needle Aspiration• Use a 3, 5, 10 or 20 mL syringe. Use of a “Syringe Pistol” is optional. • Needle should be at least 1 ½ inch or appropriate length and be 22 to

25 gauge. • Single end label clear glass slides (for preparation of direct smears).• Fixative to preserve fixed slides (either Cytology spray fixative,

Saccomanno fixative or 95% ethyl alcohol in coplin jar).

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Fine Needle AspirationPalpate and identify mass or lesion.

Clean topically with alcohol.

Stabilize the mass with non-dominant hand.

Insert needle through the skin with a quick motion.

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Fine Needle Aspiration• Advance through the subcutaneous

tissue into the mass. Aim needle toward the center of small masses but toward the periphery of larger masses as the center may be necrotic.

• A noticeable difference in the consistency of the tissue should be noted when the needle penetrates the mass.

• With the needle in the mass, the needle tip should be moved in short motions initially to loosen cells within the mass.

• Pull back on plunger to create negative pressure. Fowler 2011 ©

Fine Needle Aspiration• Without releasing pressure, withdraw

the needle within the target slightly then reinsert at a slightly different angle.

• Repeat maneuver several times before complete withdrawal. May also perform a corkscrew action before withdrawal.

• If blood or material appears in the hub of the needle, the aspiration should be stopped.

• Release negative pressure before withdrawing the needle, negative pressure must be released to prevent suction of the material into the barrel of the syringe when the needle exits the skin.

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Preparing Slides

Transfer specimen from needle hub to slides.

Gently and evenly spread specimen between two slides before fixing. Allow to

air dry before closing slide holder.

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Fine Needle Aspiration

Aspiration techniques vary widely based on personal preference, and specific clinical

circumstances.

Goal is to collect adequate cellular

material for cytologic evaluation.

Practice mannequins available to palpate and

practice technique.

Peritonsillar Abscess


History• Severe Odynophagia• Dysphagia

Physical• Fever• Unilateral edema• Hot Potato Voice• Elevated white count

(CBC)• CT Scan with contrast

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Strong clinical suspicion without obvious physical findings.


Equipment neededHurricaine sprayLidocaine w/ epi

Tongue BladeScalpel

HeadlightSuction setup

Long tonsil clampCulturette

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Peritonsillar Abscess• Management options

– Needle aspiration– Incision and Drainage– Quinsy tonsillectomy

• Choice will depend on site and location of abscess. Smaller, deep abscess are sometimes easier to reach with large bore needle.

• Both have similar success rates (Needle Aspiration 90-95% vs I and D 90-100%)



Needle Aspiration


Incision & Drainage with #15 blade Blunt Disection with curved hemostat

Incision and Drainage



Discharge instruction :

Penicillin based antibiotics

Oral prednisone

In-office follow up, possible tonsillectomy

Practice mannequins available to simulate PTA and practice needle aspiration technique.


Tracheostomy Care

Clinical Consensus Statement: Tracheostomy Care

• Clinical consensus statement (CCS) Aims to improve care for pediatric and adult patient with a tracheostomy tube.

• Approaches to tracheostomy care are currently inconsistent among clinicians and between different institutions.

• The goal is to reduce variations in practice when managing patient with a tracheostomy to minimize complications.

• Variations in care and management of patient with a tracheostomy exist between hospitals, inpatient and outpatient facilities, and in the emergency room.

• Presently, the current literature does not support the development of clinical practice guidelines but favors a consensus of expertise.

Selection of Tracheostomy Tracheostomy tubes come in different sizes and different

materials. Two types of tracheostomy tubes commonly used are Polyvinyl

chloride tracheostomy tubes (Shiley) and Silicone (Bivona). Shiley tubes are slightly flexible and Bivona are the most flexible.

Both Shiley and Bivona tubes come standard with a universal adapter for ventilation. In double cannula tubes, the inner cannula is inserted and locked in place after the obturator is removed.

The inner cannula can be removed briefly for cleaning. The outer tube is secured to the paitent. Single cannula tubes are often used in children and do not have an inner cannula.

Selection of Tracheostomy

Fenestrated tracheostomy tubes facilitate speech by allowing better translaryngeal air flow. Some clinicians believe that fenestrated tubes also aid in the clearance of secretions. Other clinicians feel that these tubes promote the development of granulation tissue along the tracheal wall at the level of the fenestrations. Since there is little scientific data to support either opinion, it is up to surgeon’s preference. Cuffed tubes have a balloon at the distal end of the tube and allow for mechanical ventilation. Uncuffed tubes are generally preferred in children. Except when requiring ventilation with high pressures, requiring ventilation only at night, or with chronic translaryngeal aspiration.

Obstruction


1. Position the patient’s head with a roll under the shoulders. Ensure that the outer opening of the tube is clear.

2. Check that the tube is in the proper location. It should be against the neck, and the obturator should not be in place.

3. If the patient has a fenestrated tube, remove the decannulation plug.

4. Give oxygen (over the tracheostomy tube), then looses secretions by placing up to 1 to 2 ml of normal saline into the tube.

5. Suction the tube with a suction catheter set to 100 mmHg or less. Insert the suction catheter approximately 2 to 3 inches into the tube. If the patient begins to cough, the catheter is through the tube and into the trachea, and the depth of insertion is correct. Do not use suction while inserting the catheter, and never force the catheter.

6. Cover the suction port (hole) and suction for 3 to 5 seconds, while slowly removing the catheter. Never suction for longer than 10 seconds.

7. Always monitor the patient’s heart rate and color during this procedure. Stop suctioning immediately if the heart rate begins to drop or the patient becomes blue.

8. If the obstruction is removed, and the patient can breathe on his/her own, do not suction further. If additional suctioning is needed, apply oxygen (by blow-by or direct ventilation) and repeat steps

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Accidental Decanulation

• Early accidental decanulation.

• Nasal speculum• Obturator• Risk of false

tract/fistula

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Leaks

A low-pressure, high volume cuff is preferred to avoid unnecessary injury to the tracheal mucosa such as tracheal malacia.

1. Check cuff pressure first.

2. Consider changing to a longer tracheostomy tube.

3. Monitor cuff pressure on a regular basis.

Shiley® Tube Size

Leak Test Volume

10 20cc

8 17cc

6 14cc

4 11cc

Bleeding

• Local bleeding– Granulation tissue– Superficial bleeding

from mucosa– Small vessels

• Controlled with – Pressure dressing– Gelfoam– Chemical

cauterization

Bleeding

But for anything more than oozing. Must rule out tracheo-innominate artery fistula (TIAF).

Caused include;• Low

tracheostomy • High innominate

artery • Cuff overinflation • Infection

Bleeding

• TIAF may cause massive hemorrhage in 0.7% of tracheotomies.

• 2/3 occur in first 3 weeks after tracheostomy

• Long-term intubation and ventilation.

• Cuffed or uncuffed tube.

Changing Tracheostomy• In the absence of aspiration, tracheostomy tube cuffs should be

deflated when the patient no longer requires mechanical ventilation.• A patient initial tracheostomy tube should normally be replaced within

10-14 days.• The Panel agreed an experienced physician should ideally be present

for the first tube change, although there are was recognition that in some facilities, this may not be feasible and thus performed by an experienced advanced practice provider (APP) with immediate physician backup available.

• In an emergency, a dislodged, mature tracheostomy tube should be replaced with the same size or a size smaller tracheostomy tube. If those are not available for could not be inserted, then an appropriately sized endotracheal tube should be placed through the wound into the trachea. In a patient in whom a tube could not be replaced, resulting in hypoxia or concern for eventual loss of airway, they should undergo oral tracheal intubation or immediate surgical revision tracheostomy.

Decannulation When the adult patient is in the hospital and;

1. Does not require mechanical ventilation

2. Indication for tracheotomy has resolved

3. Patient tolerates breathing through the tracheotomy tube with the cuff deflated.

4. Breathing with a cuffless #6 Shiley tube is checked (smaller patients, a cuffless #4 Shiley tube is placed)

5. Patient tolerates capped tracheostomy with a red button.

6. If the patient is stable (normal oxygen and CO2) for 24 – 48 hours with the trach plugged, the tube will be removed by a qualified physician or mid-level provider, and the stoma will be allowed to close.

Downsizing, capping and decannulation

Decannulation

Downsizing, capping and decannulation

Decannulation

1. Wound margins should heal by secondary intention, with initial wound co-apting in 5 to 7 days (unless wound was created with a fenestration technique)

2. New epithelial cells grow across wound in 7 to 10 days. No leak of air from the wound at this time.

3. If wound does not heal, then wound may be closed surgically, by separating trachea from the skin, and closing the wounds in layers.

4. If scar appearance is not acceptable, wound may be closed in a transverse incision across the lower neck with a plastic closure.

When the patient succeeds at decannulation sequence,

Decannulation

Assess the patient for associated anomalies of the nervous, respiratory, cardiovascular and gastro-intestinal systems.

Re-examine the airway for associated problems: nasal obstruction, adenoid hypertrophy, tonsil hypertrophy, macroglossia, glossoptosis, micrognathia, lingual tonsil hypertrophy, laryngomalacia, glottic web, sub-glottic stenosis, tracheal stenosis or granulation

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Late Complications

• Bleeding • Tracheomalacia• Stenosis • Tracheoesophageal

fistula• Tracheocutaneous

fistula• Granulation• Leaks

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Tracheotomy- Conclusion

1. Identify source of leaking and bleeding.

2. If unable to safely change tracheostomy at bedside consider revision tracheostomy in OR.

3. Care of the tracheostomy tube and the wound require planning and communication.

4. Do only as much as you have been trained to, feel comfortable doing and is within your scope of practice. Practice mannequins

available to practice tracheostomy care

technique.

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Clinical Consensus Statement

• Tracheostomy tube should be changed using a clean technique. A sterile technique is not necessary and does not lead to a reduction in impaction.

• Plastic tracheostomy tube should be used among pediatric and adult patients for initial tube placement.

• Tracheostomy tube ties it should be used unless the patient recently underwent local or free flap reconstructive surgery or other major neck surgery.

• No patient should be discharged with tracheostomy tube sutured in place. Any suture securing a tracheostomy should be removed during first tube change.

• Stoma and tracheostomy tube should be suctioned when there is evidence of visual or audible secretions in the airway, suspected airway obstruction, and whether tube is changed or deflated.

Links

Aaron’s Tracheostomy Pagehttp://www.tracheostomy.com/

http://www.tracheostomy.com/

Station 1Control

A/PEpistaxis

Removal FB

Station 4PTA

Station 2Control

A/PEpistaxis

Removal FB

Station 5FNA

Station 3Trach Care

Station 6FNA

ENT Procedures Practice StationsS

MR

*

Chair

*suction

ENT Procedures Jason Fowler, MPAS, PA-C Jose C. Mercado, MMS, PA-C April 26-28, 2013 New York-Presbyterian Hospital/Weill Cornell Medical Center.

Documents

floor of anterior

left anterior nasal

posterior nose bleeds

practice tracheostomy

minutes mercado

following removal

direct manual pressure

fiberoptic nasal endoscopy