Tympanoplasty

Tympanoplasty
It is an operation to (I) emdicme disease in the middle car
and ( ii) to rec.on stnict heming mechanism. It may be combmcd
wirh mastOldectomy if disease proce~s so nen1~li n s .
TYr€'". of minnie ear reconstructi.on dcpcnJs on r.he d(lm(lge
present in the ea r. The procedure m(lY be limited only to
repair of tympanic memhrane (myringoplast),), or to reconstruc
tion of oss icular chain (ossicuioplaslY), or both (l)'m-
1}{1T1lJl)U1.~t),). Reconsffilcrive surgery of the car has heen
gready facihcared by development of opcrating microscope,
microsurgical instruments and hi(Kompatible implant
materials.
Front the ph)'1'iiology uf hearing mech anism, the follow~
ing principles can be ded uced Lo reslOre hearing surgicillly:(i) An intact tympanic memhrane, to provide large
hydraulic ralio between the rympanic membrane
and stapes f(.:x) tplate.
(ii) Ossicular chain , to conduct sound from tympa nic
membrane ro (he oval window.
( iii) Two funcCluning windows, one 011 the scala veslibuli
([0 receJve sound vibrations) ~nd lhe other on the
scala rympani (to act as <.I re lief window). If it is only
one Window, as in smpes fixation or closurc of round
Window, (here will he no movement uf cochlem
fluids re::.ultin~ in conductivt: he;)[lng loss.
(Lv) Acou.~ tic separation of twO wirnlool.l's, so that sound
does not" reach bo th the 'windows simultaneo usly.
It can be achie ved by providlllg an inrac t tympanic
membrane, prefe re ntia l I,athway to o ne window
(usually the uvcd.) by providing o~::;icu lar c hain and
by the prese nc.e of air in thc miJdle e~r.
(v) Functioning cus wchian tube) to provide J,erthe lUlddle eat.
(v i) A functioning sensorineum/ apparatus, I.e. t he
cochlca and Vllltb ncrv e.
Types of tympanoplasty. Wullstein c l ~ssi fied l ympano~
pl"sry into five types (Fig. S.2).
Type I De fcCl is perforation of tympanic membrane
which i1'i repaired with a graCe It i~ also cill l~rI
myringoplasLY.
Type II Defect is perforation of tymparuc: mc: mhl~lte
with ero~iO n of m~lIel..1s. Uraft is placed un the
incus o r rt:rnn~nt of malleus.
Type III M""eu, and incus are ahscnt. Gra(t is placed
di recd y on the stapes head . it is als() called
mY"ingostapcdiopcX)' flf" columella tympano·
plasty.
T ype IV Only the (ootplutc of stapes is present. Ir is
exposcJ LO the eXTernal ear, and grafr is placed
between the oval and round wiuJows. A narrowmiddle e-al (cClvum minor) is rhus ereattn , to
h~V(' ~n nir pocket around rhe round willdow. A
mlK'( )Sn~ l iTleJ SI);)CC cx(ends from the eustachian
(Ube ro [he round window. Sound wa vc~ in this
case ::let di recrly on the footp late whil ~ the
rou nd window h as been shielded.
Type V Stapes footplate is fix ed hllr round wLndow i::;
iunctioning. In such ('8~CS, another window is
crerlteJ un hOfl2ontal semlC ircular canal and
covered with rt graft. A lso catted fenestration
operation .
Several modificat ions h", ve rJPpeared in the above
classificarion and they mainly perta in [U lhe types of
ossiculnr reconstruction.
My ringoplasty. It is tepair

Bronchoscopy

Bronchoscopy is of two types:
1. Rigid .
2. Flexible fibre optic.
RIGID BRONCHOSCOPY
Indications
A. Diagnostic
[ . To find out the cause for wheezing, haemoptysis,
or unexp lained cough persisting for more than
4 weeks.
2. When X- ray chest sho ws:
(a) Atelectasis of a segment, lobe or entire lung
(b) Opacity localised to a segment or lobe of lung
(c) Obstructive emphysema-to exclude foreign body
(d) Hilar or mediastinal shadows
3. Vocal cord palsy.
4. Collection of bronchial secretions for culture and
sensitivi ty tests, acid fas t bacilli, fun gus, malignant
cells.
8. Therapeutic
1. Removal of foreign bod ies.
2. Removal of retained secretions or mucus plug in
cases of head injuries, chest trauma, thoracic or
abdomi nal surge ry, or comatosed patients.
Anaesthesia
General anaesthesia with no endotracheal tube or with
only a small bore catheter is often preferred. It can also
be done under topical surface anaesthes ia.
Position
Same as fordirect laryngoscopy.
Technique
There are two methods to in trod uce bronc hoscope:
1. Direct method. Here bronchoscope is introduced
directly through the glottis.
2. Through laryngoscope. Here glo ttis is first exposed
with the help of a spatular type laryngoscope and
then the bronchoscope is introduced through the
laryngoscope into the trachea. Laryngoscope is then
withdrawn. This me thod is useful in infan ts and
young children, and in ad ults who have short neck
and thick tongue.
Details of Technique
l. A piece of ga uze is placed on the upper teeth for the ir
protect ion aga inst injury.
2. Proper-sized bronchoscope is lu bricated with a swab
of autoclaved liquid paraffin or gelly. It is held by the shaft
in surgeon's right hand in a pen- like fashion. Fingers of
the left hand are used to retract the upper lip and guide
the bronchoscope.
3. Now looking through the scope, tip of epiglottis is
identified first and the scope passed behind it and the
epiglottis lifted forward to expose the glottiS. Now bronchoscope
is rotated 90° clockwise so that its bevelled tip
is in the axis of glottis to ease its entry into the trachea.
Once trachea is entered, scope is rotated back to the original
position.
4. Bronchoscope is grad ually advanced and the entire
tracheobronchial tree examined. Axis of bronchoscope
should be made to correspond with axes of the trachea
and bronchi. To ac hieve this, head and neck are flexed
to the left when examining the right bronchial tree and
vice versa.
Openi ngs of all the segmental bronchi in both the
lungs are examined seriatim.
5. Direct vision, right angled and retrograde telescopes
can be used for magnification and detailed examination.
6. Biopsy of the les ion of susp icious area can be taken.
7. Secretions can be collected for exfoliative cytology,
or bacteriologic examination.
Post-operative Care
1. Keep the patient in humid atmosphere.
2. Watch for respiratory distress. This could be due to
laryngeal spasm or subglottic oedema if the proced ure
had been unduly prolonged or the bronchoscope
introduced repeatedly. Inspiratory stridor and suprasternal
retraction will ind icate need for tracheostomy.
Complications
1. Injury to teeth and li ps.
2. Haemorrhage from the biopsy site.
3. Hypox ia and cardiac arrest.
4. Laryngeal oedema.
Precautions During Bronchoscopy
l. Select proper size of bronchoscope according to
patient's age (see Table A 1).
2. Do not force bronchoscope thro ugh closed glott is.
3. Repeated removal and introduction of bronchoscope
should be avoided.
4. Procedure shou ld not be prolonged beyond 20 minutes
in infants and children, otherwise it may cause
subglottic oedema in pos t-operati ve period.
FLEXIBLE FIBRE OPTIC BRONCHOSCOPY
These days, flexible fibre optic bronchoscopy has
replaced rigid bronchoscopy for diagnostic procedures
particularly in adults. It provides magnification and better
illumination, and because of the smaller size, permits
examination of subsegmental bronchi. It is also easy to
use ll1 patients with neck or jaw abnormalities where rigid
bronchoscopy may almost be impossible technically.
This procedure can be performed under topical anaesthesia
and is very useful for bedside examination of the critically
ill patients. The suction/biopsy channel provided
in the fibrescope helps to remove secretions, inspissated
plugs of mucus or even small foreign bodies. Flexible
bronchoscope can also be easily passed through endotracheal
tube or the tracheostomy opening. However, it has
limited utiltty in children because of the problems of
ventilation.

Oesophagoscopy

Oesophagoscopy is of two types:
1. Rigid oesophagoscopy.
2. Flexible fibre-optic oesophagoscopy.
RIGID OESOPHAGOSCOPY
Indications
A. Diagnostic
1. To inves tigate cause for dysphag ia, e. g. cancer
oesophagus, cardiac achalas ia, strictures, oesophagitis,
diverticula, etc.
2. To find cause for retrosternal burning, e.g. reflux
oesophag itis or hiatus hernia.
3. To find cause for haematemesis, e.g. oesophageal
varices.
4. Secondaries neck with unknown primary (as a pan
of panendoscopy).
B. Therapeutic
1. Remova l of a foreign body.
2. Dilatation in case of oesophageal strictures or card
iac achalas ia.
3. Endoscopic removal of benign lesio ns, e. g. fibrom a,
papilloma, cysts, etc.
4. Insertion of Soutar's or Mou sseau ~B a rb in tube in
palliati ve treatment of oesophageal carcinoma.
5. Injection of oesophageal varices.
Contraindications
l.
2.
Trismus-makes the procedure technically difficult.
Disease of cervical spine, e.g. cervical trauma, spondylosis,
tu be rculous sp ine, osteophytes, kyphos is. They
make rigid oesophagoscopy technically difficult. Flexible
fibre -optic oesophagoscopy is performed in these
cases.
3. Receding mandible.
4. Aneurysm of aorta for fear of rupture and fatal haemorrhage.
5. Advanced heart, liver or kidney disease may be a
relative contraindication.
Anaesthesia
Genenll anaesthesia with oro-tracheal intubation, with
tube in the left corner of the mouth. it can be performed
under local anaesthesia in seleC(ed ind ividuals.
Position
Same as for direct laryngoscopy. Patient lies supine, head
is elevated by 10-15 cm, neck flexed on chest, and head
extended at adanto-occipital jo int. The purpose of this
positio n is to attain the axes of mouth, pharynx and
oesophagus in a straight line to pass the rigid tube easily.
This position can be achieved with the help of an ass istant
or a special head rest.
Technique
1. A piece of gauze is placed over the upper teeth to
protect teeth and lips.
2. Oesophagoscope is lubricated with a swab of autoclaved
liquid paraffin or jelly.
3. The oesophagoscope is held by its proximal end in
a pen-like fashion and introduced into the mouth
by the right side of the tongue and then towards the
midd le of its dorsum.
Now there a re 4 basic steps:
1. Identification of drytenoids. Once oesophagoscope
has been introduced to the back of tongue, it is
advanced gently by the left thumb and index finge r.
Epiglo ttis is first seen , then the endotracheal tube
and a little furth er down arytenoids can be identified.
2. Passing the cricophar)'ngeal sphincter. Keeping the tip
of oesophagoscope stric tly in the midline, behind
the larynx, it is lifted with movements of left thumb
to open the h ypopharynx. With slow but sustained
pressure, the sph incter will open and then the tip of
oesophagoscope can be guided easily into the
oesophag us. Never apply force to open the sphincter.
Sometimes, a fine bougie can be lIsed to find the
lumen. An add itional dose of muscle relaxant may
be required if sphincter does not open. Once oeso~
phagus has been entered, it is easier to advance the
scope, provided, oesophagea l lumen is kept constantly
in view.
3. Crossing the aortic arch and left bronchus. In an adult.
this natural narrowing lies about 25 cm from the
incisors. Aortic pulsa tion can be seen . When cro~sing
this area, head of the patient is slightly lowe red
so that oesophageal lumen is in line with that of the
scope.
4. Passing the cardia. Head and shoulders remain be 10\\'
the level of the table, head being slightly higher
than the shoulders and moved slightly to the right
At this stage, the oesophagoscope points to the lefr
ante rior-superior iliac spine. Cardia is identified b)
its redder and more velvety or rugose mucosa.
Never forget to inspect the oesophageal wall again
when the oesophagoscope is withdrawn.
Post-operative Care
1. Sips of plain water followed by usual diet may be
given in an uneventful oesophagoscopy.
2. Pat ient is watched for pain in the interscapular region,
surgical emphysema of neck, and ahrupt rise of temperatu
re. They indicate oesophageal perfora tion.
Complications
1. Injury to lips and teeth.
2. InJulY to ar)' tenoids.
3. Injur )' to pharyngeal mucosa. They are al l the result of
careless technique and can be avoided.
4. Perforation of oesophagus. Most often it occurs at the
site of Killian's dehiscence (near cricopharyngeal
sphincter) when undue force has been used to l'ass
the oesophagoscope. Surgical emphysema develops
within an hOLlr or so and the patient complains of
pain in the interscapular region. This may be complicated
by abscess in retropharyngeal space or
mediastinum ..
5. Compression of trachea. Oesophagoscope may press on
posterior tracheal wall, especially in child ren, causing
obstruction to respiration and cyanosis. Treatment is
immediate withdrawal of oesophagoscope.
FLEXIBLE FIBRE OPTIC OESOPHAGOSCOPY
Irs main ad va ntage over the rigid oesophagoscopy is
that it is an outdoor procedure , does not require general
anaesthes ia and can be used in patients wi th abnormalities
of spine or jaw where rigid endoscopy is technica
lly difficult. The oesophagus, stomach and duodenum
can all be examined in one sitting. Good illumination
and magni ication provided by the fibrescope helps in
the accurate diagnosis of the mucosa l disease affecting
these sites an.J permits taking of prec ision biopsies,
remova l of small fore ign bodies or benign tumours,
dila tation of webs or strictures and even injection of
bleeding varices with scleroSing agents. In ca 'es of malignant
disease, oesophrtgeal stent can be placed as a palliative
measure.
The procedure is pelfonned under local anaesthesia
with or without intravenous sed ation. The patient lies in
left lateral position and fib r>scope is pas eJ th rough a plastic
mouth prop inro the pharynx, post-cricoid area and
oesophagus, insufflating air as the endoscope is advanced,
to open tl1e lumen of oesophagus. These days flexible fibre
optic oesophagoscopy has practically replaced rigid
oesophagoscopyexc pt in some cases of foreign bodies.

Adenoidectomy

Adenoidectomy may be indicated alone or in combination
with tonsillectomy. In the latter event, adeno ids are
removed first and the nasopharynx packed before sta rting
tonsillectomy.
Indications
1. Adeno id hypertrophy causing snor in g, mouth
breathing, sleep apnoea syndrome or speech abnormaliti
es, i.e. (rhino lalia clausa).
2. Recurrent rhinosinusitis.
3. Chronic secretory otitis media associated with adenoid
hype rplas ia.
4. Recurrent ear discharge in benign CSOM associated
with adeno iditis/adenoid hyperplasia.
5. Dental malocclusion. Adenoidectomy does not correct
dental abnormalities but will prevenr its recurrence
after orthodontic treatment.
Contraindications
1. Cleft palate or submucous palate. Removal of adenoids
causes velopharyngeal insufficiency in such cases.
2. Haemorrhagic diathesis.
3. Acute infection of upper respiratory tract.
Anaesthesia
A lways general, with ora l endocracheal intubation.
Position
Same as for tonsillectomy. Hyperextension of neck should
always be avoided.
Steps of Operation
1. Boyle-Davis mouth-gag is inserted. Before actual
removal of adenoids, nasopharynx should always be
examined by retracting the soft palate with curved
end of the tongue depressor and by digital pa lpation ,
to confirm the diagnos is, to assess the size of adenoids
mass and to push the lateral adeno id mas:es
towards the midline.
2. Proper size of "adenoid curette with guard" is introduced
into the nasopharynx till its free edge touches
the posterior border of nasal septum and is then
pressed backwards to engage the adenoids. At this
level, head shou ld be slightly flexed to avoid injury
to the odontoid process.
3. With gentle sweep ing move ment, adenoids are shaved
off (Fig. 91.1) . Late ral masses are simi larly removed
with smaller curettes; small tags of lymphoid tissue
left behind are removed with punch forceps.4. Haemostasis is achieved by packing the area for
sometime. Persistent bleeders are electrocoagulated
under vision. If bleeding is still not controlled, a
postnasal pack is left for 24 hours.
Endoscopic Adenoidectomy
These days adeno ids can be removed more precisely by
using a debrider under endoscopic concro!.
Post-operative Care
Sdme as in tonsil lectomy. There is no dysphagia and
patient is up and about early.
Complications
l. Haemorrhage, usually seen in immed ia te postoperative
period. Nose and mouth may ' be full of
blood or the only indication may be vomitus of darkcoloured
blood which the patient had been swallowing
gradually in post-operative period. Ri sing pulse
rate is another indicator. Treatment is same as for
per-operat ive haemorrhage. Postnasal pack under
general anaesthesia is often requi red.
2. Injury to eustachian tube opening.
3. Injury to pharyngeal musculature and vertebrae. This is
due to hyperex tension of neck and undue pressure of
curette. Care should be taken when operating patients
of Down's syndrome as 10-20% of them have atlantoaxial
instability.
4. Velophar)lngeal insufficienc)l.
5. Nasopharyngeal stenosis due to scarring.
6. Recurrence. This is due to regrowth of adenoid tissue
left behind.

Tonsillectomy

Indications
They are d ivided inro:
A. Absolute
1. ReculTent infections of throat. This is the most common
indication. Recurrent infections are further defi ned as:
(a) Seven or more episodes in one year, or
(b) Five episodes per year fo r 2 years, or
(c) Three ep isodes per year for 3 years, or
(d) Two weeks or more of lost sch ool or work in one
year.
2. PeritonsiliLlr absces~. In children, tonsillectomy is done
4-6 weeks after abscess has been treated. In adults,
second attack of peri tonsillar abscess forms the
ahsolute indication.
3. Tons ill itis causing febrile se izures.
4. H ypertro phy of tonsils causing
• airway obstruction (s leep apnoea)
• difficul ty in deglutition
• interfe re nce with speech.
5. Suspici.on of malignancy'. A unilaterally enlarged tonsil
may be a lymphoma in c hildren and an epidermoid
carcinoma in adults. An excisional biopsy is done.
B. Relative
1. Diphther ia carriers, who do not respond to antibiotics.
2. Streptococcal carriers , who may be the source of
infection to orhers.
3. Chronic tonsillitis with bad tas te or halitosis which
is unresportS ive to medical treatment.
4. Recurrent streptocccal tonsillitis in a patient with
valvular heart disease.
C. As a Part of Another Operation
1. Palatopharyngoplasty which is done for sleep apnoea
syndrome.
2. Glossopharyngeal neurectomy. Tonsil is removed first
and then IX nerve is severed in the bed of tonsil.
3. Removal of styloid process.
Contraindications
1. Haemoglobin level less than 10 g%
2. Presence of acute infection in upper respira tory
tract, even ac ute tonsillit is. Bleeding is more in the
presence of acute infection.
3. Children under 3 years of age. They are at poor
surgica I risks.
4. Overt or submucous cleft palate.
5. Bleeding disorders, e.g. leukaemia, purp ura, aplastic
anaemia, haemophilia.
6. At the time of epidemic of polio.
7. Uncontrolled systemic disease, e.g. diabetes, cardiac
disease, hypertension or asthma.
S. Tonsillectomy is avoided during the period of menses.
Anaesthesia
Usually done under ge neral anaesthesia with endotracheal
intubatio n. In adu lts, it may be done under loca l
anaest hesia.
Position
Rose's position, i. e. patient lies supine with head
extended by plac ing a pillow under the shoulders. A rubber
ring is placed under the head to stabilise it (Fig. 90.1).
Hyperextension shou ld always be avo ided.
Steps of Operation (Dissection and
Snare Method)
1. Boyle-Davis mouth gag is introduced and opened. It
is held 111 place by Draffin 's bipods or a string over a
pulley (Fig. 90.2).2. Tonsil is grasped with tonsil-holding forceps and
pulled medially.
3. Incision is made in the mucous membrane where it
reflects from the tonsil to anterior pillar. It may be
extended along the upper po le to mucous membrane
between the tonsil and posterior pillar.
4. A blunt curved sc issor may be used to dissect the
tonsil from the peritonsillar tissue and separate its
upper pole.
5. Now the tonsil is held at its upper pole and trac tion
applied downwards and media ll y. Dissection is continued
with tonsillar dissector or scissors until lower
pole is reached (Fig. 90.3).
6. Now wire loop of tonsillar snare is threaded \.wer the
tonsil on to its pedicle, tightened, and the pedicle
cut and the tonsil removed.
7. A gauze sponge is placed in the fossa and pressure
applied for a few minutes.
8. Bleeding points are tied with silk. Procedure is
repeated on the other side.
Post-operative Care
1. Immediate general care
(a) Keep the patient in coma position until fully recovered
from anaesthesia.
(b) Keep a watch on bleeding from the nose and mouth.
(c) Keep check on vital signs, e.g. purse, respiration and
blood pressure.
2. Diet. When patient is fully recovered he is permitted
to take liquids, e.g. cold milk or ice cream. Sucking of ice
cubes gives relief from pain. Diet is gradually built from soft
to solid food. They may take custard, jell y, soft boiled eggs
or slice of bread soaked in milk on the 2nd day. Plenty of flu ids
should be encouraged.
3. Oral hygiene. Patient is given Condy's or salt
water gargles 3-4 times a da y. A mouth wash with plain
water after every feed helps to keep the mouth clean.
4. Analgesics. Pain, locally in the throat and referred
to ear, can be relieved by analgesics like paracetamol. An
analgesic can be given half an hour before meals.
5. Antibiotics. A suitable antibiotic can be· giv en
rally or by injection for a week.Patient is usually sent home 24 hou rs after operation
unless there is some complication. Patient can resume his
normal duties within 2 weeks.
Other methods for tonsillectomy (Table 90.1)
1. Guillotine method Largely abandoned. It can be
done ani y when tonsils are mobile and tonsil bed has not
been scarred by repeated infections.
2. Electrocautery. Both unipo lar and bipolar e lectrocautery
has been used. It reduces blood loss but causes
thermal injurr to tissues.
3. Laser tonsillectomy. !t is indica ted in coagu lat ion disorde
rs. Both KTP-5 I 2 and CO2 lasers have been used but
the former is preferred. Technique is similar to one used in
dissection method.
4. Laser ronsillorom)' , Another method is laser tonsillotomy
which aims to reduce the size of tonsils. It is indicated
in patients who are unable to tolerate general
anaesthesia. Tonsils are reduced by laser ablation up to
ante rior pillars by stage repeated applications.
5. Intmcapsular tonsillectomy. With the use of powered
instruments (debrided tonsil is removed but its capsule is
preserved in the hope to reduce post-operative pain.
6. Harmonic scalpel. It uses ultrasound to cut and coagulate
tissues. It is a cold method with less tissue damage
and post-operative pain compared to electrocautery
t,echnqu e.
7. Plasma-mediated ablation technique. In this ablation
method, protons are energized to break molecular bonds
between tissues. It is a cold method and does not cause
thermal injury.
8. Coblation tonsil/ectom)'.
9. Cr)'osurgical technique. Tonsil is frozen by app lication
of cryoprobe and then allowed to thaw. Two applications,
each of 3-4 minutes, are applied. Tons illar tissue will
undergo necrosis and later fall off leav ing a granulating
surface. Bleeding is less due to thrombosis of vesse ls
caused by freezing.
Complications
A. Immediate
1. Primary haemorrhage. Occurs at the time of operation.
It can be contro lled by pressure, ligation or electrocoagulation
of the bleeding vessels.
2. Reactionary haemorrhage. Occurs within a period of 24
hours and can be controlled by simple measures such as
removal of the clot, application of pressure or vasoconstrictor.
Presence of a clot prevents the clipping action of
the superior constrictor muscle on the vessels which pass
through it (compare post-partum uterine bleeding). If
above measures fail, ligation or electrocoagulation of the
bleeding vessels can be done under general anaesthesia.
3. Injur)' to tonsillar pillars, uvula, soft palate, tongue or
superior constrictor muscle due to bad surgical technique.
4. Injury to teeth.
5. Aspiration of blood.
6. Facial oedema. Some patients get oedema of the face
particularly of the eyelids.
7. Surgical emphysema. Rarely occurs due to injury (()
superior constrictor muscle.
B. Delayed
1. Secondary haemorrhage . Usually seen between the 5rh
to 10th posr-ope rative day. It is the result of sepsis and
premature separation of the membrane. Usually, it is heralded
by bloodstained sputum but may be profuse.
Sim ple measu res like removal of clot, topical application
of dilute adrenaline or hydrogen peroxide with pressure
usually suffice. For profuse bleeding, genera l
anaesthesia is given and bleeding vessel is electrocoaglllated
or ligated. Sometimes, approximation of pillar.with
mattress sutures may be required. Sometimes, external
carotid ligation may also be required.
Transfu sion of blood or plasma, depending on blooJ
loss, is given. Systemic antibiotics are given for control or
infection.
2. Infection. Infection of tonsillar fossa may lead t(
parapharyngeal abscess or otitis med ia.
3. Lung complications. Asp irat ion of blood, mucus ,lr
tissue fragments may cause atelectasis or lung abscess.
4. Scarring in soft palate and pillars.
5. Tonsillar remnants. Tonsil tags or tissue, left due tl
inadequate surgery, may get repeated ly infected.
6. Hypertrophy of lingual tonsil. This is a late complication
and is compensatory to loss of palati ne tonsils.
Sometimes, lymphoid tissue is left in the plica triangu ,
laris near the lower pole of tonsil, which later gets hype rtrophied.
Plica triangularis should, therefore be removed
during tonsillectomy.

Direct Laryngoscopy

It is direct visualisa tion of larynx and hypopharynx.
Indications
A. Diagnostic
1. When indirect laryngoscopy is not possible as in
infants and young children, and the symptomato logy
points to larynx and/or hypopharynx, e.g. hoarseness,
dyspnoea, stridor and dysphagia.
2. When indirect laryngoscopy has not been successful,
e.g. due to excessive gag reflex or overhanging
epiglo ttis obscuring a part of the complete view of
the larynx.
J. To examine hidden areas of:
Hypo/)har)'nx: Base of tongue, va lleculae and lower
part of pyriform fossa.
Larynx: Infrahyoid epiglottis, anterior commissure,
ventricles and subglottic region .
4. To find the extent of growth and take a bio psy.
B. Therapeutic
1. Removal of benign lesions of larynx, e.g. papilloma,
fibroma, vocal nodule, polyp or cyst.
2. Remova l of foreign bodies from larynx and
hypopharynx.
J. Dilatation of laryngeal stric;tures.
Contra indications
1. Diseases or injuries of cervica l spine.
2. Moderate or marked dyspnoea unless the airway has
been provided by tracheostomy.
J. Recent coronary occlusion or cardiac decompensatio
n.
Anaesthesia
General anaesthesia is preferred though this procedure can
be performed under local anaesthesia. In infants and young
children, no anaesthesia may be required if procedure is for
diagnostic purpose.
Position
Patient lies supine. Head is elevated by 10-15 cm by
placing a pillow under the occiput or by ra ising h ead flap
of the operation table. Neck is flexed on thorax and the
head extended on adamO-OCCipital jo int (Barking-dog
position) .
Procedure
1. A piece of gauze is placed on the upper teeth to protect
them. aga inst trauma.
2. Laryngoscope is lubricated with a little autoclaved
liqu id paraffin.
J. Laryngoscope is held by the handle in the left hand .
Right hand is used, to retract the lips and guide the
laryngoscope and to handle suction and instru ments.
4. Laryngoscope is introduced by one side of the
to ngue which is pushed to the oppos ite side till posterior
third of to ngue is reached. It is then moved to
the midline and lifted forward to bring the epiglo ttis
in view.
5. Laryngoscope is now advanced behind the epiglottis
and lifted forward without levering it on the upper
tee th or jaw (Fig. 87.1). This gi ves good view of the
interior of the larynx.
6. If anterior commissure laryngoscope is being used,
its t ip can be advanced further between the ventricular
bands to examine the ventricles and anterior
commissure . It can be passed between the vocal
cords to examine the subglottic region .
7. Following struc tures are examined seria lly: Base of
tongue, right and left valleculae, epiglottis, (its tip,
lingual and laryngeal surfaces ), right and left pyriform
sinuses, aryepiglottic fo lds, arytenoids, postcricoid
region, both false cord s, anter ior and
posterior commissure, right and left ventricles, right
and left voca l cords and subglottic area. Mobility of
voca l cords sh ould also be observed.
A right-angled te lescope can be used to see the undersurface
of voca l cords and the walls of the subglottis .
After rhe procedure is completed, laryngoscope is withdrawn
and lips and teeth examined for any injury.Post-operative Care
1. Patient is kept in coma position to prevent aspiration
of blood or secretions.
2. Patient's respiration should be watched for any
laryngeal spasm and cyanosis.
3. Trauma to larynx, especially if repeated attempts
at laryngoscopy have been made. It may lead to
laryngeal oedema and respiratory distress.
4. Bleeding may occur from the operative site. Patient
may spit blood. Care should be taken to prevent
aspiration.
Complications
1. [njury to lips and tongue if they are nipped between
the teeth and the laryngoscope .
2. [njury to teeth. They may get dislodged and fall into
pharynx.
3. Bleeding.
4. Laryngeal oedema.

Endoscopic Sinus Surgery

Endoscopic surgery has made a great contribution towards
management of sinus disease. Indications for conventional
operations like those of Caldwell-Luc, frontal sinus operations,
external ethmoidectomy have greatly reduced.
Endoscopic surgery is minimally invasive surgery and does
not require skin incisions or removal of intervening bone
to acces, the disease. In the sinuses, ventilation and
drainage of the sinuses is established preserving the nasal
and sinus mucosa and its function of mucociliary clearance.
Advances in endoscopic surgery have been possible due to;
1. Development of better optics.
2. Improved brighter illumination.
3. Development of microsurgical instruments to work
with the endoscopes and precise removal of tissue
with sharp cuts without stripping the mucosa.
4. Concomitant developments in imaging techniques
like CT and MRI to precise ly define the area of
pathology.
5. Introduction of powered instrumentation in the form
of sofr-t i ~s ue shavers also called micro-debriders (to
remove n asa l polyps, soft-tissue masses or mucosa)
help reduce bleeding to a great extent while bonecutting
drills help endoscopic surgery of frontal sinus,
hcrimal sac , etc. to remove bony obstruction.
6. The lar ' t advancement has been the computerassisted
image-guided navigational surgery in difficult
cases or revisional surgery when landmarks are
not easy to identify.
Indications
1. Chronic bacterial sinusitis unresponsive to adequate
medical treatment.
2. Recurrent acute bacterial sinusitis.
3 . Polypo id rhinosinusitis (diffuse nasal polypos is) .
4. Fungal sinusitis with fung<11 ball or nasal polypi.
5. Antrochnanal p()lyp.
6. Mucoce le 0 frontoethmo id or sph enoid sinus.
7. Con trol oi epistclx is by endoscopic cautery.
8. Remova l of foreign body from the nose or sinus.
9. Endoscopic se ptoplasty.
Advanced Nasal Endoscopic Techniques
1. Removal of benign tumours, e.g. in ert d papillomas
or angiufibromas.
2. Orbital abscess or cellulitis management.
3. Dacryocystorhinostomy.
4 Repair of CSF leak.
5. Pituitary surgery.
6. Optic nerve decompress ion.
7. Orbital decompression for Graves disease.
8. Control of posterior epistaxis (endoscopic clipping
of sphenopalatine artery).
9. Choanal atresia.
Contra i nd icati ons
1. Inexperience and lack of proper instrumentation.
2. Disease inaccess ible by endoscopic procedures, e.g.
lateral front al sinus disease and stenosis of internal
opening of frontal sinus.
3. Osteomyelitis.
4. Threatened intracranial or intraorbital complication.
Anaesthesia
General anaesthesia is preferred by most of the surgeons.
Local anaesthesia with i.v. sedation can be used in
when limited work is to be done.
Position
Patient lies flat in supine position with head rest ing ,m a
ring or head rest. Some also prefer to raise it by IS°
Techniques
Two surgical techniques are followed;
(a) Anterior to posterior (Stammberger's technique ); In
this technique surgery proceeds from uncinate
process backward to sphenoid sinus. Advantage of
this technique is to tailor the extent of surge ry to
the extent of disease.
(b) Posterior to anterior (Wigand's techniq ue ); Surgery
starts at the sphenoid sinus and proceecls anteriorly
along the base of skull and medial orbital wall. This
is mostly done in extensive polyposis or in revisional
sinus surgery.
Steps of Operation
1. Remove the pledgees of cotton kept for nasal decongestion
and topical anaesthesia.
2. Inspect the nose with 4 m.m 0° endoscope or do
complete nasal endoscopy if not a lready done.
3 . Inj ect submucosa lly 1 % lignocaine with 1:100, 00
adrenaline under endoscopic control (Fig. 861):
(a) On the lateral wall, near the upper end of midelk
turbinate.
(b) On the la teral wall, just below the first
inj ect ion.
(c) On the la teral \vall, just above the inferior
turbinate.
(d) In the middle turbinate, posterior aspec t.
(e) Posterior aspect of nasal septum.
4. Replace cotton pledgets and repe at injections on
the opposite side if bilateral FESS is to be done.Medialise the middle turbinate and identify the unc inate
process and bulla ethmoida lis. If middle turbinate is large ,
partial or total turbinectomy is performed . In case of concha
bullosa, lateral lamella is removed. Definitive surgical
steps include:
1. Uncinectomy. Uncinate process is incised with
sickle knife and remo ved with Blakesley forceps.
2. Identification and enlargement of maxillary
ostium. Maxillary ostium lies above the inferior
turbinate and posterior to lower third of uncinate
process. Once localised, it is enlarged anteriorly with
a back-biting forceps or pos teriorly with a through
cut-s tra ight forceps.
3. Bullectomy. Bulla ethmoidal is is penetrated with
curette or Blakesley forceps and removed. Avoid
injury to medial orbital wa ll, skull base or anterior
ethmoidal artery.
4. Penetration of basal lamella and removal of posterior
ethmoid cells. Basa l lame lla is the dividing thin
bony septum between anterior and posterior ethmoid
cells. It is penetrated in the lower and medial part
with a sma ll curette and then removed with Blakesley
forceps. Posterior ethmoid cells are exenterated. Optic
nerve is at risk if Onodi cell is present. Onodi ce ll is
a pos terior ethmoid cell which extends into the sphenoid
bone late ral and superior to the sphenoid sinus.
5. Clearance of frontal recess and frontal sinusotomy.
Iffrontal sinus is clear on CT scan and patient
also does not suffer from fremea I h eCldaches, nothing
need to be done. In the event of fron tal sinus disease
, front al recess is cleared and frontal sinus
drainage established.
Opening of frontal sinus is situated lateral to
attachment of middle turbinate, medial to medial
orbital wa ll, anterior to anterior ethmoidal artery
and posterior to agger nasi cell{s). Surgery in the area
of frontal recess is challenging as any d isrespect to
the mucosa in this area would lead to stenosis of
frontal sinus opening with mucocele formation o r
recurrent frontal sinusitis6. Sphenoidotomy. This step is done after clearance of
pos terior ethmo id cells or Clfter frontal sinuso tomy.
It is omitted if sinus is hea lthy. In this procedure
ante rior wall of sphe noid sinus is removed, and pus
and inspi ssa ted mat erial from wit hin the sinus
removed. There are two ways to remove the anterior
sinus wa ll:
(a ) By entering the sphenoid s inus anterior and
inferior to the ethmo id cavity created by the
above steps.
(b) By enlarging the opening of sphenoid sinus with
Bla kesley forceps or J -curette. Sinus opening is
identified after removal of the posterior-inferior
portion of superior turbinate near the nasal septum
and about 1.0 cm above the upper border of
posterior choana.
7. Nasal packs. Fina lly the nasal packs are aprlied, if
septal surge ry has also been done with FESS o r to
stop any bleed ing from the nasa l cavity.
Post-operative Care
It is individua lised according to the exten t of surgery
done.
I. Removal of nasal packs. Nasa l packs, if kept, are
removed at the time of discharge 24 hours
operation.
2. Antibiotics. An intraopera tive intravenous antibi otic
(amoxyclav, cephalosporin or quinolone) is
administered and then continued for 7-10 days by
oral ro ute.
3. Antihistaminics. For a llergic patients.
4 . Analgesics. For re lief of post-opera ti ve pa in.Nasal irrigations. Saline irrigations are started after 1
week post-operatively to remove blood clots, crusts and
secretions and continued once or twice a day for 1 week.
Steroid nasal sprays. Required in cases of nasal
allergy or those operated fo r nasa l polyps.
Endoscopic toilet. Blood clots, crusts and debris are
removed by suction and forceps from the ethmoid area lateral
to middle turbinate. Any adhesion fonl1ation in the
nose is di vided with suction. Healthy mucosa should not
be disturbed. Suction can be done from within the maxillary
sinus wirh a curved cannula. Since the endoscopic
clearance is a painful process, topical nasal anaesthetic
with a decongestant is sprayed before the procedure.
Patient pays weekly visits for inspection of the cavity
for 4 weeks and there after as required till mucosalisation
of the cavity is complete.
Complications
They are similar to conventional surgery of ethmoid complex
and can be divided into major and minor. Mostly they
involve orbit or skull base, or are of general nature
Major
1. Orbital haemorrhage
2. Loss of vision/ blindness
3. Diplopia
4. (SF leak
5. Meningitis rhinitis or sinusitis
6. Brain abscess
7. Massive haemorrhage
8. Intracranial haemorrhage
and direct brain trauma
9. Anosmia
10. Injury to internal carotid
artery in sphenoid sinus
11. Injury to nasolacrimal
duct and epiphora
12. Death

Minor:
1. Periorbital ecchymosis2. Periorbital emphysema 3. Post-operative epistaxis4. Post-operative infection:5. Adhesions6. Stenosis of maxilla ry 0r frontal sinus
requiring blood transfusion7. Exacerbation of asthma8. Hyposmia9. Dental pain

Diagnostic Nasal Endoscopy

Like anterior and posterior rhinoscopy, endoscopy of nose
and nasopharynx helps in the diagnosis of diseases of
nose, paranasal sinuses (PNS) and the nasopharynx.
Because of the brighter illumination, magnification and
angled view provided by the endoscopes, it is possible to
examine all clefts and crevices of the nose and nasopharynx.
It is an important part of examination of nose and
nasopharynx.
Indications
1. To diagnose any disease of the nose and PNS.
2. To diagnose source of bleeding in epistaxis.
3. To assess response to medical or surgical treatment
of the nose and PNS disease.
4. To take a precise biopsy from nose and nasopharynx.
Anaesthesia
Topical anaesthesia with 4% xylocaine and a vasoconstrictor
(oxymetazoline), first as a nasal spray and then
nasal packs.
Position
Sitting or supine.
Instruments
1. 4 mm 30° endoscope
2.7 mm 30° endoscope } Required when nasal
2.7 mm 70° endoscope passages are narrow
2. Freer's elevator or elevator with a suction channel
3. Suction tips
4. Biopsy forceps
5. Antifog solution or savlon to prevent fogging of the
endoscopic lens.
Technique
After nasal packs are removed, endoscopy is performed by
three passes:
First Pass (Examination of nasopharynx and
inferior meatus)
1. First obtain a general view of the nasal cavity. Look
for any septal deviation or spurs and their size,
mucous or purulent discharge in the nasal cavity and
colour of the nasal mucous membrane.
2. Pass the endoscope along the floor of nose into the
nasopharynx and examine: (i) opening of eustachian
tube, (ii) walls of nasopharynx, (iii) upper surface of
soft palate and uvula, and (iv) opening of eustachian
tube of opposite side. To see these structures endoscope
is rotated.
3. Withdraw the endoscope slightly and examine the
margins of choana and posterior ends of turbinates.
4. Withdraw endoscope slowly and at the same time
examine inferior meatus for opening of nasolacrimal
duct and Hasner's valve. Slight pressure over the
lacrimal sac may express a drop or two of lacrimal
fluid through the nasolacrimal opening.
Second Pass (Examination of the
sphenoethmoidal recess, superior meatus
and openings of sphenoid sinus and
posterior ethmoidal cells)
Endoscope is passed medial to middle turbinate to examine
posterior part of middle turbinate, sphenoethmoidal
recess, superior turbinate and meatus, opening of posterior
ethmoid cells (in the superior meatus) and opening of
sphenoid sinus in the posterior wall of sphenoethmoidal
recess between the nasal septum and superior turbinate.
Third Pass (Examination of the
middle meatus in detail)
Endoscope is passed from the front into the middle meatus.
Sometimes middle turbinate needs to be displaced medially
or 2.7 mm 30° endoscope have to be used. Examine
uncinate process, bulla ethmoidalis, hiatus semilunaris,
sinus of the turbinate (cavity on lateral side of middle
turbinate) and the frontal recess.
Sometimes middle meatus is better entered from
behind where the space is wider than from the front and
structures are seen from behind forward, e.g. basal lamina,
bulla ethmoidalis, hiatus semilunaris, sinus of the turbinate
and uncinate process and the frontal recess.
Complications
Sometimes bleeding can occur due to suction or manipulation
of instruments. It is usually mild and easily controlled
by vasoconstrictor nasal drops.

Submucous Resection of Nasal Septum And Septoplasty

Indications
1. Deviated nasal septum (DNS) causing symptoms of
nasal obstruction and recurrent headaches.
Z. DNS causing obstruction to ventilation of paranasal
sinuses and middle ear, resulting in recurrent sinusitis
and otitis media.
3. Recurrent epistaxis from septal spur.
4. As a part of septorhinoplasty for cosmetic correction
of external nasal deformities.
5. As a preliminary step in hypophysectomy (trans-septal
trans-sphenoidal approach) or vidian neurectomy
(trans-septal approach).
Contraindications
1. Patients below 17 years of age. In such cases, a conservative
surgery (septoplasty) should be done.
Z. Acute episode of respiratory infection.
3. Bleeding diathesis.
4. Untreated diabetes or hypertension.Anaesthesia
Local anaesthesia is preferred. General anaesthesia is
used in children and apprehensive adults.
Position
Reclining position with head-end of the table raised.
Steps of Operation
1. Infiltration of nasal septum. It is done in its subperichondrial
planes with 2% xylocaine and 1:50,000
adrenaline.
2. Incision. A curvilinear incision with forward
convexity is made at the mucocutaneous junction on the
left side of the septum. It cuts only through the mucosa
and perichondrium.
3. Elevation of mucoperichondrial and periosteal
flap. Plane of dissection is important. It should be
beneath the perichondrium and periosteum (Fig. 83.1A).
4. Incision of the cartilage. Cartilage is incised just
posterior to the first incision. Avoid cutting the opposite
mucoperichondrium, otherwise, it will result in perforation.
5. Elevation of opposite mucoperichondrium and
periosteum. With the elevator passed through the cartilage
incision, mucoperichondrial and periosteal flap is
raised from the opposite side of the septum (Fig. 83.1 B).
6. Removal of cartilage and bone. Now working
between the two flaps, cartilage and bone are removed.
Cartilage can be removed with Ballenger swivel knife
and bone with Luc's forceps. Bony spur or ridge can be
removed with gouge and hammer. Preserve a strip of cartilage
about 1 cm wide along the dorsal and caudal border
of the septum to prevent collapse of the bridge of
nose or retraction columella (Fig. 83.2).
7. Stitching. One or two catgut or silk stitches are
applied in the initial mucoperichondrial incision.
S. Packing. Ribbon gauze, smeared with an antibiotic
ointment or liquid paraffin, is packed in each nasal cavity
to prevent collection of blood between the flaps. Nasal
dressing is applied.
Post-operative Care
1. Patient is placed in semi-sitting position to prevent
oozing of blood. Outer nasal dressing is changed if
soaked in blood.
Z. A soft diet should be taken in the first two postoperative
days to minimise active mastication
which causes bleeding.
3. Pain, if any, should be controlled with analgesics.
4. Antibiotic cover is given for 5-6 days.
5. Nasal packs are gently removed after 24 hours and
thereafter, decongestant nasal drops and steam
inhalations are given daily for 5-6 days.
6. Silk stitch, if any, is removed on 5th or 6th day.
7. Patient should avoid trauma to the nose for
several days.
Compl ications
1. Bleeding. It may require repacking, if severe.
2. Septal haemawma. Evacuate the haematoma and
given intranasal packing on both sides of septum for
equal pressure.
3. Septal abscess. This can follow infection of septal
haematoma.
4. Perforation. When tears occur on opposing side of
mucous membrane.
5. Depression of bridge. Usually occurs in supratip area
due to too much removal of cartilage along the dorsal
border.
6. Retraction of columella. Often seen when caudal strip
of cartilage is not preserved.
7. Persistence of deviation. It usually occurs due to inadequate
surgery and may require revision operation.
8. Flapping of nasal septum. Rarely seen, when too much
of septal framework has been removed. Septum,
which now consists of two mucoperichondrial flaps,
moves to the right or left with respiration.
9. Toxic shock syndrome. It is rare after septal surgery. It
can follow staphylococcal (sometimes streptococcal)
infection and is characterised by nausea, vomiting,
purulent secretions, hypotension and rash. It should
be diagnosed early. It is treated by removal of packing,
hydrating the patient, maintaining blood pressure and
administering proper antibiotics.

SEPTOPLASTY:
Septoplasty is a conservative approach to septal surgery; as
much of the septal framework as possible is retained.
Mucoperichondrial/periosteal flap is generally ra ised
only on one side. This operation has almost replaced the
SMR operation.
Indications
1. Symptomatic deviated septum.
2. As a part of septorhinoplasty for cosmetic reasons.
3. As an approach to hypophysectomy.
4. Recurrent epistaxis due to septal spur.
Contraindications
1. Acute nasal or sinus infection.
2. Untreated diabetes.
3 . Hypertension.
4. Bleeding diathesis.
Anaesthesia
Local or general.
Position
Same as for SMR operation.Technique
1. Infiltrate the septum with 1 % lignocaine with ad renaline,
1:100,000.
2. In cases of deviated septum, make a slightly curvilinear
incision, 2-3 mm above the caudal end of septal
cartilage on the concave side (Killian's incision).
In case of caudal dislocation, a transfix ion or hemitransfixion
(Freer's) incision is made.
3. Raise mucoperichondrial/mucoperiosteal flap on
one side only.
4. Separate septal cartilage from the vomer and ethmoid
plate and raise mucoperiosteal flap on the opposite
side of septum.
5. Remove maxillary crest to realign the septal cartilage.
6. Correct the bony septum by removing the deformed
parts. Deformed septal cartilage is corrected by various
methods, such as:
(i) Scoring on the concave side (Fig. 84.1).
(ii) Cross-hatching or morcelizing.
(iii) Shaving.
(iv) Wedge excision.
Further manipulations like realignment of nasal spine,
separation of septal cartilage from upper lateral cartilages,
implantation of cartilage strip in the columella
or the dorsum of nose may be required.
7. Trans-septal sutures are put to coapt mucoperichondrial
flaps.
8. Nasal pack.
Post-operative Complications
Same as for SMR operation.
1. Bleeding.
2. Septal haernatorna and abscess.
3. Septal perforation.
4. Persistence of septal deviation, or external nasal
deformity.

Caldwell-Luc Operation

Caldwell-Luc operation is a process of opening the maxillary
antrum through canine fossa by sublabial approach
and dealing with the pathology inside the antrum.
Indications
1. Chronic maxillary sinusitis with irreversible changes
in the sinus mucosa.
2. Removal of foreign bodies or root of tooth.
3. Dental cyst.
4. Oroantral fistula.
5. Suspected neoplasm in the antrum and its biopsy.
6. Recurrent antrochoanal polyp.
7. Fracture of maxilla or blow-out fractures of the orbit.
8. As an approach to ethmoids (Horgan's transantral
ethmoidectomy) .
9. Approach to pterygopalatine fossa for ligation of
maxillary artery.
10. Vidian neurectomy.
Contra indications
Patient below 17 years of age.
Anaesthesia
General anaesthesia with cuffed endotracheal tube and a
pharyngeal pack. Can be done under local anaesthesia.
Position
Reclining with head-end of the table raised. Patient lies
supine with face turned slightly to the opposite side.
Technique
1. Incision. A horizontal incision with its ends upward
is made below the gingivolabial sulcus, from lateral incisor
A
to the 2nd molar (Fig. 82.1). It cuts through mucous
membrane and periosteum.
2. Elevation of flap. The mucoperiosteal flap is raised
from the canine fossa to the infraorbital nerve avoiding
injury to the nerve .
3. Opening the antrum. Using cutting burr or gouge
and hammer, a hole is made in the antrum. Opening is
enlarged using Kerrison's punch.
4. Dealing with pathology. Once maxillary antrum
has been opened, pathology is removed. Diseased antral
mucosa can be removed with elevators, curettes and
forceps. Cyst, benign tumour, foreign body or a polyp is
removed .
5. Making nasoantral window. A curved haemostat
is pushed into the antrum from the inferior meatus and
then this opening is enlarged with Kerrison's and sidebiting
forceps to make a window, 1.5 cm in diameter.
6. Packing the antrum. Rihhon gauze. impregnated
with liquid paraffin or Furacin ™ (Furacin ™ is 0.2% w/w
nitrofurazone) ointment can be packed in the antrum
and its end brought out from the nasoantral window into
the nose. Intrasinus packing is done if there is severe
bleeding. Pack is also kept in the nose.
7. Closure of wound. Sublabial incision is closed
with one or two catgut sutures.
Post-operative Care
1. Ice packs over the cheek in the fi rst 24 hours prevent
oedema. haematoma and discomfort to the patient.
2. Packing in the sinus and nose can be removed in
24-48 hours.3. Antibiotics are given for 5-7 days.
4. Patient should avoid blowing his nose for 2 weeks to
avoid surgical emphysema.
Complications
1. Post-operative bleeding. This can be controlled by
nasal pack.
2. Anaesthesia of the cheek due to stretching of
infraorbital nerve. It may last for a few weeks or
months.
3. Anaesthesia of teeth.
4. Injury to nasolacrimal duct.
5. Sublabial fistula .
6. Osteomyelitis of maxilla (rare).

Myringoplasty

Closure of perforation of pars tensa of the tympanic membrane
is called myringoplasty. It has the advantage of:
(i) restoring the hearing loss and in some cases the
tinnitus.
(ii) checking re-infection from external auditory canal
and eustachian tube (nasopharyngeal infection
ascends easily via eustachian tube in the presence
of perforation than otherwise).
(iii) checking aeroallergens reaching the exposed middle
ear mucosa, leading to persistent ear discharge.
Myringoplasty can be combined with ossicular reconstruction
when it is called tympanoplasty.
Physiologic principles for middle ear reconstruction
are discussed on page 32.
Contra indications
(i) Active discharge from the middle ear.
(ii) Nasal allergy. It should be brought under control
before surgery.
(iii) Otitis extema.
(iv) Ingrowth of squamous epithelium into the middle
ear. In such cases, excision of squamous epithelium
from the middle ear or a tympanomastoidectomy
may be required.
(v) When the other ear is dead or not suitable for
hearing aid rehabilitation.
(vi) Children below 3 years.
Anaesthesia
Local or general, the former is preferred.
Position
Supine with face turned to one side; the ear to be operated
is up.
Graft materials used are:
(i) Temporalis fascia (most common),
(ii) Perichondrium from the tragus,
(iii) Tragal cartilage,
(iv) Vein.
Incision for exposure of tympanic membrane depends
on the size of the ear canal; it may be endomeatal, endaural
or posta ural.
Technique
Underlay Technique
1. Harvesting the graft of temporal is fascia or perichondrium
from the tragus.
2. Preparing the T.M. for grafting. An incision is
made along the edge of perforation and the ring of
epithelium removed. Remove also a strip of mucosal
layer from the inner side of perforation.
3. Inspecting the middle ear. A stapes-type incision
is made and the tympanomeatal flap raised to see the
integrity and mobility of the ossicular chain and to
ensure that no squamous epithelium has grown into the
middle ear.
4. Placing the graft. Middle ear is packed with
gelfoam soaked with an antibiotic. A proper sized graft is
placed so that its edges extend under the margins of perforation
all round and a small part also extends over the
posterior canal wall. Tympanomeatal flap is replaced. An
underlay technique has the advantage that the squamous
epithelium is not buried in the middle ear.
Overlay Technique
1. Temporal fascia or perichondrial graft is harvested as
above.
2. Incision is made in the meatus as shown (Fig. 79.1)
and meatal skin raised along with all epithelium from the
outer surface of tympanic membrane remnant.
3. Graft placed on the outer surface of TM. A slit is
made in the graft to tuck it under the handle of malleus.
4. Meatal skin removed earlier is now replaced, covering
the periphery of the graft. Ear canal packed with gelfoam
and then with a small antibiotic pack.
A modification of the overlay technique is to place
the anterior edge of fascia graft under the annulus after
removing the epithelium. This prevents blunting of anterior
canal which is seen as a complication of overlay
technique .
5. Closure of endaural or postaural incision.
6. Mastoid dressing.
Post-operative Care
l. Stitches are removed after 5-6 days.
2. Ear pack is removed after 5-6 days without disturbing
the gelfoam.
3. Patient is seen at 3 and 6 weeks after operation.
4. Complete epithelialisation of graft takes 6-8 weeks.
Complications
Underlay Technique
l. Middle ear becomes narrow.
2. Graft may get adherent to the promontory.
3. Anteriorly, graft may lose contact from the remnant of
tympanic membrane leading to anterior perforation.
Overlay Technique
l. Blunting of the anterior sulcus.
2.Epithelial pearls. They are epidermal cysts, when
squamous epithelium is buried under the graft.
3.Lateralisation of graft. Graft loses contact from the
malleus handle resulting in conductive loss. It is prevented
by tucking the graft under the handle.
Other Procedures for Closure of Tympanic
Membrane Perforation
1. Splintage. It is used in fresh traumatic perforations.
The torn edges of the petforation are carefully everted
lmder the microscope and splinted with absorbable gelfoam
placed in the middle ear through the tear. Smaller tears can
be splinted on the outer surface of the tympanic membrane
with a piece of cigarette paper, gelfilm or silicon sheet.
2. Cautery-patching. This is useful in small, longstanding
central perforations where the margins, have
become epithelialised and chronic. In this procedure,
margins, of the perforation are cauterised with 50%
trichloracetic acid to remove the epithelialised edge (or
freshened with a fine pick used for myringoplasty) and
then supported with a cigarette paper moistened with
1 % phenol in glycerine. This procedure can be repeated
at two weeks interval. Instead of cigarette paper, other
material such as steristrip, gelfilm or silicone sheets have
also been used .
3. Fat-graft myringoplasty. It is also used to close
small perforations. After local anaesthesia, edges of perforation
are freshened with 1 mm stapes hook. The inside
of perforation is also scrapped. A small piece of fat harvested
from the ear lobule is plugged into the perforation
like an hour-glass. Over a time, the fat graft adheres and
closes the perforation.

Radical Mastoidectomy

Radical Mastoidectomy is a procedure to eradicate disease
from the middle ear and mastoid without any attempt to
reconstruct hearing. Posterior meatal wall is removed and
the entire area of middle ear, attic, antrum and mastoid is
converted into a single cavity. All remnants of tympanic
membrane, ossicles (except stapes footplate) and mucoperiosteallining
are removed (Fig. 77.1). Eustachian tube is
obliterated by a piece of muscle or cartilage. Aim of the
operation is to permanently exteriorise the diseased area
for inspection and cleaning. The radical mastoidectomy is
infrequently required these days.
Indications
1. When all cholesteatoma cannot be safely removed,
e.g. that invading eustachian tube, round window
niche, perilabyrinthine or hypotympanic cells.
2. If previous attempts to eradicate chronic inflammatory
disease or cholesteatoma have failed.
3. As an approach to petrous apex.
4. Removal of glomus tumour.
5. Carcinoma middle ear. Radical mastoidectomy followed
by radiotherapy is an alternative to en bloc
removal of temporal bone in carcinoma middle ear.
Anaesthesia
Mos tly, general anaesthesia is given. Local anaesthesia
can be used in selected cases.
Position
Patient lies supine with face turned to one side and the
ear to be operated upper-most.
Steps of Operation
1. Incision. Postaural (Fig. 77.2) or endaural
(Fig. 77.3).
Horizontol
Eust. tube
opening closed
with muscle
ROIJr:vl w.i.r.I.rlnw
Fig. 77.1 Radical mastoidectomy. The entire area of
mastoid, middle ear, attic and antrum is exteriorised.
Eustachian tube is obliterated and no attempt is made to
reconstruct the hearing mechanism .
2. Retraction of soft tissues and exposure of mastoid
area. Mastoid area from posterior root of zygoma to
behind the suprameatal triangle and from temporal line
above to the lower part of mastoid tip below is exposed
by elevating the periosteum and the wound retracted.
3. Removal of bone and exposure of attic and
antrum. With the help of burr, bone is removed from
the area of suprameatal triangle, spine of Henle, root of
zygoma to just above the anterior meatal wall, upper part
of superior meatal wall is also removed. This will expose
attic and antrum. Identify the tegmen antri and lateral
semicircular canal.4. Removal of the "bridge" and the buttresses.
Deeper part of superior osseous meatal wall that bridges
over the notch of Rivinus is removed.
Anterior spine of the notch (anterior buttress) and
posterIor spIne of th.e notc.h. (posterior buttre",,) are abo
removeJ. This removes the late ral attic wall. The incus
and the malleus are also removed.
5. Lowering the facial ridge. The deeper part of posterior
meatal wall that overlies the vertical part of facial
nerve is called facial ridge. It is removed as much as possible
within the safety of VIIth nerve so that the mastoid
cavity is freely accessible from the meatus.
6. Toilet of middle ear. Remnants of tympanic
membrane with its annulus and sulcus tympanicus are
removed. Middle ear mucoperiosteum along with any
polyp or granulation tissue is removed. Malleus and incus
are removed if not already done. Stapes is left intact.
Eustachian tube opening is closed by curetting its mucosa
and plugging the opening with tensor tympani muscle or
piece of cartilage.
7. Inspection of the cavity and irrigation. It is necessary
to ensure complete exteriorisation of the attic,
antrum and middle ear and mastoid cavity into external
aud itory meatus . Any bony overhangs are removed and
cavity smoothened with polishing burr. Finally, it is irri gated
with saline to remove any blood or bone particles.
8. MeatopIasty. A flap, based laterally at the concha
is raised from posterior and superior meatal wall and
turned into the mastoid cavity to cover the area of the
facial ridge. This helps in the epithelialisation of the
mastoid cavity. A piece of conchal cartilage can be
removed to enlarge the meatus and to facilitate inspection
and access to cavity.
9. Obliteration of the cavity. If mastoid cavity is
very large, it may be obliterated with temporalis muscle
or other soft tissues, taking care that no vestige of disease
(cholesteatoma) is buried underneath .
10. Closure of wound. The cavity is packed with
ribbon gauze, impregnated with an antibiotic/antiseptic
and the wound is dosed withmterrupted suture:.
Masto id dressing is applied.
Post-operative Care
1. Dressing. First dressing is done on 3rd or 4th day
Replace the outer gauze and cotton and look for any
signs of perichondritis or infection of meatal pack.
Second dressing is done on 6th or 7th day when stittches
are removed and meatal pack is changed. Thereafter
change the pack at weekly intervals or leave the cavity
unpacked with regul ar suction and cleaning till
epithelialisation is complete.
2. Antibiotic. A suitable antibiotic is given for about
week.
3. Cavity care. Usually, cavity is fully epithelialised in
2-3 months. It shou ld be period ically checked (every
4-6 months) in the first year and then annually .
removal of any debris or infection. Any granulation tissue
which delays epithelialisation is removed or cauterized.
Complications
1. Fac ial paralysis.
2. Perichondritis of pinna.
3. Injury to dura or sigmoid sinus.
4. Labyrinthitis, if stapes gets dislocated.
5. Severe conductive deafness of 50 dB or more. This
due to removal of all ossicles and tympanic membrane.
6. Cavity problems. Twenty five percent of the cavities
do not heal and continue to discharge, require
regular after-care.
Modified Radical Mastoidectomy: It is a modification of radical mastoidectomy where as
much of the hearing mechanism as possible is preserved.
The disease process which is often localised to the attic
and antrum is removed and the whole area fully exteriorised
into the meatus by removal of the posterior meatal
and lateral attic wall (Fig. 78.1).
Indications
1. Cholesteatoma confined to the attic and antrum.
2. Localised chronic otitis media.
Irreversibly damaged tissues are removed, preserving
the rest to conserve or reconstruct hearing mechanism.
Anaesthesia
Mostly general, local anaesthesia can be used in selected
cases.
Position
Same as for cortical mastoidectomy.
Steps of Operation
1. Incision, postaural or endaural.
2. Retraction of soft tissues and exposure of mastoid
area.
3. Removal of cortical bone and exposure of antrum
and attic.
Steps 2 and 3 are the same as in radical mastoidectomy.
4. Removal of diseased tissue. Cholesteatoma, granulations
or unhealthy mucosa is removed. Incus and head
of malleus often require removal, if cholesteatoma
engulfs them or extends medial to them. They are
preserved if possible. Lateral attic wall is removed
to fully exteriorise the attic.
5. Facial ridge is lowered.
6. Mastoid cavity is smoothened with polishing burr,
removing any overhangs and then irrigated with
normal saline.
7. Reconstruction of hearing mechanism. Pars tensa of
tympanic membrane and middle ear, if healthy, are left
undisturbed. If disease extends into middle ear, only
the irreversible tissues are removed. Reconstruction
of tympanic membrane or ossicular chain, if damaged,
can also be done (mastoidectomy with tympanoplasty
operation) .
8. Meatoplasty and closure of wound is same as in
radica l mastoidectomy.
Post-operative Care and Complications
Same as in radical mastoidectomy.

Mastoid Surgery

Myringoplasty
It is an operation in which reconstructive procedure is
limited to repair of tympanic membrane perforation.
Tympanoplasty without Mastoidectomy
(tympanum = middle ear)
It is an operation to eradicate disease in the middle ear
and to reconstruct the hearing mechanism without mastoid
surgery, with or without tympanic membrane grafting.
This means ossicular reconstruction only or ossicular
reconstruction with myringoplasty.
Tympanoplasty with Mastoidectomy
It is an operation to eradicate disease in both the mastoid
and middle 'ear cavity, and to reconstruct the hearing
mechanism with or without tympanic membrane grafting.
Cortical Mastoidectomy (Simple
Mastoidectomy or Schwartz Operation)
It is an exenteration of all accessible mastoid air cells preserving
the posterior meatal wall.
Modified Radical Mastoidectomy
It is an operation to eradicate disease of the attic and mastoid,
both of which are exteriorised into the external auditory
canal by removal of the posterior meatal and lateral
attic walls. Tympanic membrane remnant, functioning
ossicles and the reversible mucosa and function of the
eustachian tube are preserved. These structures are necessary
to reconstruct hearing mechanism at the time of surgery
or in a 2nd stage operation.
Radical Mastoidectomy
It is an operation to eradicate disease of the middle ear
and mastoid in which mastoid, midd le ear, attic and the
antrum are exteriorised into the external ear by removal
of posterior meatal wall. All remnants of tympanic membrane,
malleus, incus (not the stapes) chorda tympani and
the mucoperiosteal lining are removed, and the opening
of eustachian tube closed by packing a piece of muscle or
cartilage into the eustachian tube.
Meatoplasty
Meatoplasty is an operation in which a crescent of concha 1
cartilage is excised to widen the meatus. It is invariably
combined with all canal wall down procedures, i.e. modified
radical for periodic cleaning or inspection, and radical
mastoidectomies for easy access to the mastoid cavity, or it
is done as an isolated procedure in a sagging auricle seen in
older people. Sagging auricle obstructs the ear canal and
causes hearing loss and retention of wax.
Mastoid Obliteration
It is an operation to eradicate mastoid disease, when
present, and to obliterate the mastoid cavity.
Obliteration of mastoid cavity is done with pedicled temporalis
muscle or musculofascial tissue raised as flaps.
SURGICAL APPROACHES TO THE
EAR AND INCISIONS
1. Endomeatal or transcanal approach. It is used to
raise a tympanomeatal flap in order to expose the middle
ear. Rosen's incision is the most commonly used for
stapedectomy. It requires the meatus and canal to be wide
enough to work. It consists of two parts; (a) a small vertical
incision at 12 o'clock position near the annulus and (b) a
curvilinear incision starting at 6 o'clock position to meet
the 1st incision in the posterosuperior region of the canals,
5-7 mm away from the annulus (Fig. 76.1) Posterior
meatal canal skin is raised in continuity with tympanic
membrane, after dislocating the annulus from the sulcus. It
gives a good view of the middle ear and ossicles. Stapes, if
still covered by posterosuperior overhang of bony meatus,
can be exposed by removing this part of the overhang. This
incision is also used commonly for exploratory tympanotomy
to find cause for conductive hearing loss, inlay
myringoplasty or ossicular reconstruction.2. Endaural approach. It is used for:
(a) Excision of osteomas or exostosis of ear canal.
(b) Large tympanic membrane perforations.
(c) Attic cholesteatomas with limited extension into
the antrum.
(d) Modified radical mastoidectomy where disease is
limited to attic, antrum, and part of mastoid.
Endaural approach is made through Lempert's incision
(Fig. 76.2). It consists of 2 parts:
Lempert I-It is semicircular incision, made from 12
o'clock to 6 o'clock position in the posterior meatal wall
at the bony-cartilaginous junction.Lempert II-Starts from the 1st incision at 12 o'clock
and then passes upwards in a curvilinear fashion between
tragus and the crus of helix. It passes through the incisura
terminalis and thus does not cut the cartilage. Both mastoid
and external canal surgery can be done.
3. Postaural (or Wilde's) incision (Fig. 76.3). It starts
at the highest attachment of the pinna, follows the curve
of retroauricular groove, lying 1 cm behind it, and ends at
the mastoid tip. In infants and children up to 2 years of age,
the mastoid process is not developed and the facial nerve
lies exposed near its exit, and the incision therefore is slanting
posteriorly, avoiding lower part of the mastoid. Some
surgeons prefer to make the postaural incision in the sulcus
(retroauricular groove) . Postaural incision is used for:
(i) Cortical mastoidectomy.
(ii) Modified radical and radical mastoidectomy.
(iii) Tympanoplasty: when perforation extends anterior
to handle of malleus.
(iv) Exposure of CN VII in vertical segment.
(v) Surgery of endolymphatic sac.
CORTICAL MASTOIDECTOMY
Cortical mastoidectomy, known as simple or complete
mastoidectomy or Schwartz operation, is complete exenteration
of all accessible mastoid air cells and converting
them into a single cavity. Posterior meatal wall is left
intact. Middle ear structures are not disturbed.
Indications
1. Acute coalescent mastoiditis.
2. Incompletely resolved acute otitis media with reservoir
sign.
3. Masked mastoiditis.
4. As an initial step to perform:
(a) endolymphatic sac surgery
(b) decompression of facial nerve
(c) translabyrinthine or retro-Iabyrinthine procedures
for acoustic neuroma.
Figure 76.4 shows the various structures and landmarks
seen after cortical mastoidectomy.
Anaesthesia
General anaesthesia.
Position
Patient lies supine with face turned to one side and the
ear to be operated upper-most.
Steps of Operation
1. Incision. A curved postaural incision about 1 em
behind but parallel to the retroauricular sulcus, starting
at the highest attachment of pinna to the mastoid tip
(Fig. 76.3B).In infants and children up to 2 years, the incision is
short and more horizontal. This is to avoid cutting facial
nerve which is superficial in the lower part of mastoid
(Fig. 76.3C).
Incision cuts through soft tissues up to the periosteum.
Temporalis muscle is not cut in the incision.
2. Exposure of lateral surface of mastoid and
MacEwen's triangle. Periosteum is incised in the line of
first incision. A horizontal incision may be made along
the lower border of temporalis muscle for more exposure.
Periosteum is scraped from the surface of mastoid and
posterosuperior margin of osseous meatus. Tendinous
fibres of sternomastoid are sharply cut and scraped down.
A self-retaining mastoid retractor is applied.
3. Removal. of mastoid cortex and exposure of
antrum. Mastoid cortex is removed with burr, or gouge
and hammer. Mastoid antrum is exposed in the area of
suprameatal triangle (MacEwen's triangle). In an adult,
antrum lies 12-15 mm from the surface. Horizontal semicircular
canal is identified.
4. Removal of mastoid air cells. All accessible mastoid
air cells are removed leaving behind the bony plate
of tegmen tympani above, sinus plate behind and posterior
meatal wall in front.
5. Removal of mastoid tip and finishing the cavity.
Lateral wall of the mastoid tip is removed, exposing muscle
fibres of posterior belly of digastric. Zygomatic cells situated
in the root of zygoma, retrosinus cells lying between
sinus plate and cortex, behind the sinus, are removed. A
finished cavity should have bevelled edges so that soft
tissue can easily sit in and obliterate the cavity.
6. Closure of wound. MastoiJ cavity is thoroughly
irrigated with saline to remove bone dust, and the wound
is closed in two layers. A rubber drain may be left at the
lower end of incision for 24-48 hours in case of infection
or excessive bleeding. A meatal pack should be kept to
avoid stenosis of ear canal. Mastoid dressing is applied .
Post-operative Care
1. Antibiotics started pre-operatively are continued
post-operatively for at least one week. Culture swab
taken from the mastoid, during operation, may dictate
a change in the antibiotic.
2. Drain, if put, is removed in 24-48 hours and sterile
dressing done.
3. Stitches are removed on the 6th day.
Complications
1. Injury to facial nerve .
2. Dislocation of incus.
3. Injury to horizontal semicircular canal. Patient will
have post-operative giddiness and nystagmus.
4. Injury to sigmoid sinus with profuse bleeding.
5. Injury to dura of middle cranial fossa.
6. Post-operative wound infection and wound
break-down.

Myringotomy

It is incision of the tympanic membrane with the purpose
to drain suppurative or nonsuppurative effusion of the
middle ear or to provide aeration in case of malfunctioning
eustachian tube. Ventilation tube (grommet) may
also be required in the latter case.
Indications
1. Acute suppurative otitis media
(a) Severe earache with bulging tympanic membrane.
(b) Incomplete resolution with opaque drum and
persistent conductive deafness.
(c) Complications of acute otitis media, e.g. facial
paralysis, labyrinthitis or meningitis with bulging
tympanic membrane.
2. Serous otitis media.
3. Aero-otitis media (to drain fluid and "unlock" the
eustachian tube).
4. Atelectatic ear (grommet is often inserted for long-term
aeration).
Contraindications
Suspected intratympanic glomus tumour. Myringotomy
in these cases can cause profuse bleeding. Tympanotomy
is preferred.
Anaesthesia
In infants and children, always use general anaesthesia. For
adults, general anaesthesia is used only when tympanic
membrane is acutely inflamed. If there is no inflammation,
myringotomy can be done under local anaesthesia or no
anaesthesia at all.
Steps of Operation
1. Ear canal is cleaned of wax and debris.
2. Operation is ideally performed under operating microscope
using a sharp myringotome and a good suction
apparatus.
3. In acute suppurative otitis media, a circumferential
incision is made in the posteroinferior quadrant of
tympanic membrane, midway between hundle uf
malleus and tympanic annulus, avoiding injury to
incudostapedial joint (Fig. 75.lA).
4. In serous otitis media, a small radial incision is given
in the posteroinferior or anteroinferior quadrant and
all the effusion sucked out (Fig. 75.1B).
When ventilation tube is to be inserted, incision should
be just enough to admit the tube (Fig. 75.2).
Pitfalls of Myringotomy
1. When tympanic membrane is thick, incision may
remain only in the superficial layers of drumhead
without cutting through its entire thickness.
2. Incision in the posterior meatal wall. This may happen
when distinction between drum-head and posterior
meatal wall is lost, when both are inflamed.
Post-operative Care
Daily mopping of ear discharge will be required in cases
of acute suppurative otitis media. In serous otitis media,
just leave a wad of cotton wool for 24-48 hours.
Drum incisions usually heal rapidly. No water should
be permitted to enter the ear canal for at least one week,
and if a grommet has been inserted, entry of water is
prevented so long as grommet is in position.
Complications
1. Injury to incudostapedial joint or stapes.
2. Injury to jugular bulb with profuse bleeding, if jugular
bulb is high and floor of the middle ear dehiscent.
3. Middle ear infection.

Management Of Foreign Body In Respiratory Tract

Nature of Foreign Bodies
(a) Non-irritating type. Plastic, glass or metallic foreign
bodies are re latively non-irritating and may remain
symptomless for a long time.
(b) Irritating type. Vegetables or foteign bodies like
peanuts, beans, seeds, etc. set up a diffuse violent
reaction leading to congestion and oedema of the
tracheobronchi al mucosa-"vegetal bronchitis".
They also swell up with time causing ai rway obstruction
and later suppurat ion in the lung.
Clinical Features
Symptomatology of foreign body is divided into 3 stages:
1. Initial period of choking, gagging and wheezing.
This las ts for a short time. Foreign body may be coughed
out or it may lodge in the larynx or further down in the
tracheobronchial tree .
2. Symptomless interval. T he respiratory mucosa
adap ts to the presence of foreign body and initial symptoms
disappear. Symptomless interval will vary with the
size and nature of the foreign body ..
3. Later symptoms. They are caused by obstruction
to the airway, inflammation or trauma induced by the foreign
body and would depend on the site of its lodgement.
(a) Laryngeal foreign body A large foreign body may
totally obstruct the airway lead ing to sudden death
unless resuscitative measures are taken urgently. A
partially obstructive foreign body will cause discomfort
or pain in the throat, hoarseness of voice,
croupy cough, aphonia, dyspnoea, wheezing and
haemoptysis.

(b) Tracheal foreign body. A sharp foreign body will only
produce cough and haemoptysis. A loose foreign body
like seed may move up and down the trachea between
the carina and the undersurface of vocal cords causing
"audible slap" and "palpatory thud". Asthmatoid
wheeze may also be present. It is best heard at patient's
open mouth
(c) Bronchial foreign body. Most foreign bodies enter the
right bronchus because it is wider and more in line
with the tracheal lumen. A foreign body may totally
obstruct a lobar or segmental bronchus causing atelectasis
or it may ptoduce a check valve obstructionallowing
only ingress of air but, not egress, lead ing to
obstructive emphysema. For pathogenesis and clinical
picture of bronchial foreign body (see Fig. 63.2).
Emphysematous bulla may ruptu re causing spontaneous
pneumothorax. A foreign body may also shift from
one side to the other caUSing change in the physical
signs. A retained foreign body in the lung may la ter give
rise to pneumonitis, bronchiectasis or lung abscess.
Diagnosis
It can be made by detailed history of the foreign body
"ingestion", physical examinat ion of the neck and
chest and radiographs. X-rays of the following areas are
advised:
1. Soft tissue posteroanterior and lateral view of the
neck in its extended pOSition. T his can show radioopaque
and sometimes even the rad io lucent foreign
bodies in the larynx and trachea
2. Posteroanterior and lateral view of the chest.

3. X-ray chest at the end of inspiration and expiration .
Atelectasis and obstructive emphysema can be seen.
They also give indirect evidence of radiolucent
foreign bodies.
4. Fluoroscopy / videofluoroscopy. Evaluation during
inspiration and expiration can be made.
5. Bronchograms. To delineate radiolucent foreign bodies
or to evalu ate bronchiectasis.

Laryngeal foreign body. A large bolus of food
obstructed above the cords may make the patient totally
aphonic, unable to cry for help. He may die of asphyxia
unless immediate first aid measures are taken. The measures
consist of pounding on the back, turning the patient
upside down and foll owing Heimlich manoeuvre. These
measures should not be done if patient is only partially
obstructed, for fear of causing total obstruction.
Heimlich's manoeuvre. Stand behind the person, and
place your arms around his lower chest and give four
abdominal thrusts. The res idual air in the lungs may dislodge
the foreign body providing some airway.
Cricothyrotomy or emergency tracheostomy should
be done if Heimlich's manoeuvre fails. Once acute respiratory
emergency is over, foreign body can be removed
by direct laryngoscopy or by laryngofissure, if found
impacted.
Tracheal and bronchial foreign bodies can be removed
by bronchoscopy with full preparation and under general
anaesthesia. Emergency removal of these foreign bodies is
not indicated unless there is airway obstruction or they are
of the vegetable nature (e.g. seeds) and likely to swell up.
Methods to remove tracheobronchial foreign body:
1. Conventional rigid bronchoscopy.
2. Rigid bronchoscopy with telescopic aid.
3. Bronchoscopy with C-arm fluoroscopy.
4. Use of Dormia basket or Fogarty's balloon for rounded
objects.
5. Tracheostomy first and then bronchoscopy through
the tracheostome.
6. Thoracotomy and bronchotomy for peripheral foreign
bodies.
7. Flexible fibre optic bronchoscopy in selected adult
patients.

Tracheostomy

Indications for tracheostomy
A. Respiratory obstruction
1 . Infections
- Acute laryngo-tracheo -bronchitis, acute epiglottitis,
diphtheria
- Ludwig's angina, peritonsillar, retropharyngeal or
parapharyngeal abscess, tongue abscess
2. Trauma
- External injury of larynx and trachea
- Trauma due to endoscopies, especially in infants
and children
- Fractures of mandible or maxillofacial injuries
3. Neoplasms
- Benign and malignant neoplasms of larynx,
pharynx, upper- trachea , tongue and thyroid
4. Foreign body larynx
5. Oedema larynx due to steam, irritant fumes or gases,
allergy (angioneurotic or drug sensitivity), radiation
6. Bilateral abductor paralysis
7, Congenital anomalies
- Laryngeal web, cysts, tracheo -oesophageal fistula
- Bi lateral choanal atresia
B. Retained secretions
1. Inability to cough
- Coma of any cause, e.g. head in juries, cerebrovascular
accidents, narcotic overdose
- Paralysis of respiratory muscles, e.g. spinal injuries,
polio, Guillain- Barre syndrome, myasthenia gravis
- Spasm of respiratory muscles, tetanus, eclampsia,
strychnine poisoning
2. Painful cough
- Chest injuries, multiple rib fractures, pneumonia
3. Aspiration of pharyngeal secretions
- Bulbar polio, polyneuritis, bilateral laryngeal
paralysis
C. Respiratory insufficiency
- Chronic lung conditions, viz. emphysema, chronic
bronchitis, bronchiectasis, atelectasis

Types of Tracheostomy
1. Emergency tracheostomy. It is employed when airway
obstruction is complete or almost complete and there

is an urgent need to establish the airway. Intubation or
laryngotomy are either not possible or feasible in such cases.
2. Elective tracheostomy (syn. tranquil, orderly or
routine tracheostomy ). This is a planned, unhurried
procedure. Almost all operative surgical facilities are
available, endotracheal tube can be put and local or general
anaesthesia can be given. It is of two types:
(a) Therapeutic: to relieve respiratory obstruction,
remove tracheobronchial secretions or give assisted
ventilation.

(b) Prophylactic, to guard against anticipated respiratory
obstruction or aspiration of blood or pharyngeal
secretions such as in extensive surgery of tongue,
floor of mouth, mandibular resection or laryngofissure.
Elective tracheostomy is often temporary and is closed
when indication is over.
3. Permanent tracheostomy. This may be required
for cases of bilateral abductor paralysis or laryngeal stenosis.
In laryngectomy or laryngopharyngectomy, lower trachea!
stump is brought to surface and stitched to the skin.

Tracheostomy has also been divided into high, mid or
low. A high tracheostomy is done above the level of thyroid
isthmus ( isthmus lies against Il, III and IV tracheal
rings). It violates the 1st ring of trachea. Tracheostomy at
this site can cause perichondritis of the cricoid cartilage
and subglottic stenos is and is always avoided. Only indication
for high tracheostomy is carcinoma of larynx because
in such cases, total larynx anyway would ultimately be
removed and a fresh tracheostome made in a clean area
lower down. A mid tracheostomy is the preferred one and
is done through the 11 or III rings and would entail division
of the thyroid isthmus or its retraction upwards or
downwards to expose this part of trachea. A low tracheostomy
is done below the level of isthmus. Trachea is
deep at this level and close to several large vessels; also
there are difficulties with tracheostomy tube which
impinges on suprasternal notch.
Technique
Whenever possible, endotracheal intubation should be
done before tracheostomy. This is specially important in
infants and children.
Position. Patient lies supine with a pillow under the
shoulders so that neck is extended. This brings the trachea
forward.
Anaesthesia. No anaesthesia is required in unconscious
patients or when it is an emergency procedure. In
conscious patients, 1-2% lignocaine with epinephrine is
infiltrated in the line of incision and the area of dissect ion.
Sometimes, general anaesthesia with intubation is used.
Steps of Operation
1. A vertical incision is made in the midline of neck,
extending from cricoid cartilage to just above the
sternal notch. This is the most favoured incision
and can be used in eme rgency and elective procedures.
It gives rapid access with minimum of bleeding
and tissue dissection. A transverse incision , 5 cm
long, made 2 fingers ' breadth above the sternal notch
can be used in elective procedures. It has the advantage
of a cosmetically better scar (Fig. 62.1) .
2. After incision, tissues are dissected in the midline.
Dilated veins are either displaced or ligated .
3. Strap muscles are separated in the midline and
retracted laterally.

4. Thyroid isthmus is displaced upwards or divided
between the clamps, and suture- ligated.
5. A few drops of 4% lignocaine are injected into the
trachea to suppress the cough when trachea is
incised.
6. Trachea is fixed with a hook and opened with a vertical
incision in the region of 3rd and 4th or 3rd and
2nd rings. This is then converted into a circular
opening. The first tracheal ring is never divided as
perichondritis of crico id cartilage with stenosis can
result.
7. Tracheostomy tube of appropriate size is inserted
and secured by tapes .
8. Skin incision should not be sutured or packed
tightly as it may lead to development of subcutaneous
emphysema.

Complications
A. Immediate (at the time of operation):
1. Haemorrhage.
2. Apnoea. This follows opening of trachea in a
patient who had prolonged respiratory obstruction.
This is due to sudden washing out of CO2 which
was acting as a respiratory stimulus. Treatment is to
administer 5% CO2 in oxygen or ass isted ventilation.
3. Pneumothorax due to injury to apical pleura.
4. Injury to recurrent laryngeal nerves.
5. Aspiration of blood.
6. Injury to oesophagus. This can occur with tip of
knife while incising the trachea and may result in
tracheo-oesophageal fistu lao
B. Intermediate (during first few hours or days):
1. Bleeding, reactionary or secondary.
2. Displacement of tube.
3. Blocking of tube.
4. Subcutaneous emphysema.
5. Tracheitis and tracheobronchitis with crusting in
trachea.
6. Atelectas is and lung abscess.
7. Local wound infection and granulat ions.
C. Late (with prolonged use of tube for weeks and
months):
1. Haemorrhage, due to erosion of major vessel.
2. Laryngeal stenosis, due to perichondritis of cricoid
cartilage.
3. Tracheal stenosis, due to tracheal ulceration and
infection.
4. Tracheo-oesophageal fistula, due to prolonged use of
cuffed tube or erosion of trachea by the tip of tracheostomytube.
5. Problems of decannulation. Seen commonly in
infants and children.
6. Persistent tracheocutaneous fistula.
7. Problems of tracheostomy scar. Keloid or unsightly
scar.
8. Corrosion of tracheostomy tube and aspiration of its
fragments into the tracheobronchial tree.