Hi and welcome to otorhinolaryngologic surgery. I'm... wait, what did I just say? What is that word? Otorhinolaryngologic?
All right, first let's break this down, okay? Otto means ear, rhino means nose, and laryngo means throat. So what we're talking about here is ear, nose, throat surgery, or we can simplify that even more and just call it ENT surgery.
So let's take that again. Hi and welcome to the ENT surgery preview. My name is Mark Sowers and today we're going to be reviewing some of the anatomy of the ear, nose, and throat and previewing some of the surgical procedures that are done on those areas.
And we'll start with ear anatomy. And ear anatomy gets interesting because there's lots of stuff going on. We have the doohickey and the thingamajig and something's not right. Okay, that looks better.
The anatomy of the ear is broken up into three sections. We have the outer ear, the middle ear, and the inner ear. The outer ear is made up of the pinna, also known as the auricle. That's the outer portion of the ear that captures sound from all different directions and funnels it into the auditory canal, the ear canal.
And that's what channels the sound down to the eardrum, also known as the tympanic membrane. So the tympanic membrane is the eardrum. Now the eardrum separates the outer ear from the middle ear. It's an actual barrier there that separates those two sections of the ear. So as the sound is received by the tympanic membrane, it vibrates that tympanic membrane.
And this vibration is then carried through the middle ear and specifically the bones of the middle ear, the malleus to the incus, and then finally to the stapes. which then transmits those vibrations to another membrane called the oval window. And this oval window is again a solid barrier that separates the middle ear from the inner ear.
After the vibrations pass through the oval window, they enter the cochlea, which is the spiral-shaped organ here. Now you notice that the cochlea starts out wide, and it gets narrower and narrower and narrower as it goes around in that spiral. And the reason for that is because sound in those different size chambers, different frequencies of sound are going to vibrate differently. So if a very low-pitched sound comes in, it's going to vibrate in the larger portion of the cochlea. A very high-pitched sound is going to vibrate further around the spiral into some of the smaller portions of the chamber.
So the frequency of the sound determines which section of the cochlea vibrates And that's how your ear is able to determine different frequencies, different pitches in the sound. All of those signals are then carried to the brain through the cochlear nerve. Just above the cochlea and still in the inner ear are the semicircular canals. Now, these are a couple of canals.
One goes up, one sort of goes to the side. Think of these as gyroscopes. I don't know if you're familiar with a gyroscope, but basically if you spin it, it sort of keeps things steady and it always holds its position.
So these semicircular canals contain fluid and they also contain, again, very fine hairs that sense the motion of that fluid. Now think about this. If you have a canal, a tube that goes in a circle like this, around through your head, and then you tilt your head this way or you tilt your head this way, what's going to happen is the fluid is going to flow one way and then back.
And as it does, it's going to trigger those very fine hairs and that's going to send the signal to your brain. that, hey, your head is moving in this way or this way, and that's how you keep your balance. So the ears are very important for your sense of balance. The signal from these hairs is carried to the brain through the vestibular nerve, which then merges with the cochlear nerve, becomes the vestibulocochlear nerve, which you should recognize as cranial nerve number eight. So given the complexity of the ear and all these different parts that have to work together in order for sound to be transmitted, from the air all the way through to the brain, there are many different things that could go wrong and therefore there are many different surgeries that we can perform in order to correct those things.
So let's take a look at some of those here. The first surgery that we'll look at is the myringotomy. Now let's break this term down.
We have otomy, again O, and that means an opening. We're going to be creating an opening. And myring refers to the tympanic membrane or the eardrum.
So we're going to be creating an opening in the eardrum. Now, why would we do this? Well, sometimes fluid in the middle ear, again, remember that middle ear is sort of bound by the eardrum and the oval canal on both sides, and things can get stuck there.
There is a eustachian tube that runs down to the throat that sort of drains that area, but sometimes that eustachian tube can get clogged, and if it does, fluid can build up in that middle ear chamber. It can't drain out any other way. So what we're going to do is create a small incision in the eardrum itself, in the tympanic membrane, to allow any fluid in there to drain out.
And then we're going to insert a very small tube into the eardrum to help hold that incision open for at least several days or weeks until that tube eventually falls out and the condition clears. A myringotomy is a special kind of case that you'll be performing because it involves very small pieces and you've got to be very careful. controlling these very small pieces in these very delicate tiny instruments. This is not a sterile procedure, so you may not be fully gowned and gloved like you would be for other procedures, but you will at least wear some sterile gloves during the procedure.
And these procedures are also very fast. Often they can be done in 30 minutes or less, so you can do a lot of these procedures in a single day. A tympanoplasty is a little bit different in that we're sort of doing the opposite of what we did before.
In this case, we're repairing... a hole in the tympanic membrane in the eardrum. And there's lots of different reasons why a hole may appear.
Maybe somebody was using a q-tip a little too hard, or maybe there was just some sort of defect in the eardrum itself. But we can go in and repair that. And to do so, we're usually going to end up taking a graft from another part of the body, probably the temporalis fascia, which is a little piece of tissue that runs right here in front of the ear. We're going to take that tissue move it back into the eardrum itself, and suture it into place. Now, getting to the eardrum can be a little tricky.
It's kind of deep in there. So we can use a couple of different approaches to do this. One, we can use a transmeatle. Again, meatus, meaning an opening of a tube to the outside of the body. So the auditory canal meatus is the opening that goes to the outside of the body.
So we can go through the auditory canal or transcanal approach. In which case we're just looking through a speculum and doing the surgery that way. One, we can do it end aural, which means we're going through the pin or the auricle of the ear.
Or we can go retroauricular, which is behind the ear and approach the eardrum that way. Other than fluid building up in the middle ear, some of the other things that can go wrong is that there could be a little bit of a growth of tissue in the middle ear. and that tissue is going to prevent the transmission of sound through those three bones, and then possibly as that tissue grows, it could cause more and more problems. You can see here that in this case, we had a little bit of growth, and it's starting to actually cause perforations or little holes in the tympanic membrane itself as that tissue grows.
This is called a cholestetoma, and the size and the extent of this cholestetoma is going to determine just how much surgery we're going to have to perform in order to remove the whole thing. Sometimes if it's just a little bit, we're going to remove part of the eardrum, but we're going to leave the incus, malleus, and stapes in place and allow the sound to transmit through them. Sometimes we're going to remove one or more of those bones up to the point where we create a little artificial incus, malleus, and stapes.
And sometimes we'll place skin grafts all the way back to the oval window itself. So when sound enters the ear, it'll go automatically. through the oval window where it'll pass directly to the cochlea.
But on occasion, these cholestatomas will grow enough that they actually start to grow into the bone behind the ear. Now this is known as the mastoid bone or the mastoid process of the temporal bone. And it's made up of a very spongy bone.
It's got a lot of holes in it and a lot of room for this cholestatoma to grow into. And that can cause some problems because it's difficult to get into. So in this case, we're going to have to perform something called a mastoidectomy.
Ectomy meaning we're removing something. In this case, we're removing part of the mastoid bone or the mastoid process in order to get this cholecytoma all the way out of there, clear it completely out so it doesn't grow back. This can be a somewhat challenging procedure because there's lots of nerves and blood vessels in this area that we want to try to preserve as much as we can. Sometimes if we catch the cholestatoma early enough and it's only affected the stapes, or maybe there's some other problem with the stapes, we can do something called a stapendectomy.
Again, ectomy means we're removing something. In this case, we're removing the stapes, the third small bone that's attached to the oval window right before the sound is transmitted into the inner ear. Now, usually to do a stapendectomy, we're going to go through the auditory canal, usually passing through the tympanic membrane, the eardrum, And then we're going to go in, remove the old stapes, and replace it with a prosthesis.
And this prosthesis will then transmit the sound from the incus into the oval window. But sometimes even these interventions aren't enough to bring back hearing. So we have to go for the little bit higher tech approach.
And this is where we would involve something called a cochlear implant. Now, again, cochlear implant, we're talking about the cochlea. But we also include this higher tech device, which sits on the outside of the ear, which actually has a little microphone that picks up the sounds and converts them into very tiny vibrations. Now, those vibrations are going to transmit through a wire. that we're going to place into the ear, all the way back into the cochlea, and we're going to wrap that wire all the way around the cochlea, through that spiral, all the way up, and that wire is going to vibrate again at different frequencies, triggering the hairs at different points along that cochlea, and signaling different frequencies to the brain.
So now let's take a look at the anatomy of the nose. The nose is actually a lot more complex than a lot of people realize. There's lots of channels and lots of little pockets called sinuses. There's the frontal sinus that's in the frontal bone of the skull. This is where you sort of get headaches up here.
You'll get infections or inflammations of the frontal sinus. Ethmoid sinus, just as I saw it, to the side of the eyes. And the maxillary sinus down here to the side of the nose, just a little bit below the nose.
Deeper in the skull, you have a sphenoid sinus, which is in the sphenoid bone. And you have also a series of... ethmoid sinuses. It can be anywhere from 10 to 15 of these guys in there, of course, in the ethmoid bone. And all these little pockets in there make the bone lighter than it otherwise would be, but they also are a good place for things to grow that you don't want to grow there, and that can create some infections and inflammations, and sometimes we have to do some surgery to help clear that out.
Inside the nose itself and extending back into the head as the air passes through are little protruding intrusions into the nasal cavity called turbinates. These turbinates are also sometimes called conchi. So conchi or turbinates are the same thing.
They're these extensions of bone into the nasal canal as it passes back into the head. And the purpose of these turbinates is to do a couple of things. One, it moistens and humidifies the air that you're breathing in, especially on a cold day or one day when the air is very dry. As the air passes over the mucous membranes that cover these turbinates, these concae, it humidifies and warms that air so that it is in a better condition by the time it makes it to your lungs.
But the turbinates do something else as well. Again, they're covered with that mucous membrane, that little sticky stuff. So what that sticky stuff does is it grabs a hold of and filters out any dust or other debris that may be entering the nose so that it doesn't.
make it all the way down to the lungs. So where did the name turbinate come from? Well, think of turbine.
Now, a turbine is something you find in a generator that spins around and around. So a turbinate is going to take the air as it passes through the nose and spin it around and around a little bit. And when it does, it acts sort of like a Dyson vacuum cleaner.
I don't know if you've seen one of those that sort of spins the air in a circle and it spins all the dust out to the edges. Well, that's what's happening here. The turbinate is going to take the air as it passes turbinates spin that air, causing the dust to go out to the edges to stick to those mucous membranes and therefore not pass into the lungs.
So the nose has sinuses and it has turbinates or concha. So let's take a look at some of the nose surgeries that we might be involved in. Our first one is a submucosis resection, an SMR, or sometimes known as a septoplasty. In this case, we're talking about correction or fixing the plasty, means correct. of the septum.
And the septum is a thin bone and cartilage that sort of divides the nose in half. And sometimes this can get bent a little bit. It can become deviated, in which case you would have a deviated septum. And we can go in there and correct this deviation, which is then going to help straighten the nose. Now, sometimes this can be done for cosmetic reasons to help straighten the nose a little bit.
But often it's done because when the septum itself is deviated, it sort of goes at a little zigzag. it tends to block the air passages through the nose. So air doesn't pass as nicely through the nose as it otherwise should. And that can cause breathing problems.
So by straightening that septum out, it opens up those passageways and allows the patient to breathe better. This surgery is usually done through the openings of the nose called the nares. So the nares are the openings of the nose. The surgeon will go in there, usually break that septum with a little snap. and then realign it in its proper place.
So sometimes the turbinates, those little extensions that go into the nose all the way back through the nasal cavity, sometimes those may be a little bit larger than they otherwise should be, or they can become inflamed. And if they do, as they swell up, they can prevent air from passing through the nasal cavity properly. And again, the patient has trouble breathing.
So one of the things that we can do is actually go in and make those turbinates a little bit smaller. We're going to do a turbinectomy. Again, ectomy meaning removal of the turbinate. So we can take part of the turbinate away, making the channel for the air to flow a little bit larger.
A polypectomy involves removing polyps. Now, sometimes in between the concha, in between the turbinates, you can have little pieces of skin, little tags of skin that grow. And these are called polyps. And sometimes they grow large enough that they block breathing.
So we would have to go in and cut those out. Now, sometimes children will present with a congenital condition called coanal atresia. Now, in this case, the hard palate, the palate that separates the nasal cavity from the oral cavity, the nose from the mouth, sometimes that hard palate, that bone, will grow up and block the back of the nasal passage.
So, with that nasal passage blocked, the child's not going to be able to breathe through their nose. So, we can go in and remove that portion of the bone. allowing the child to breathe normally through their nose.
As I mentioned before, there's a whole bunch of little sinuses all around the nose. These sinuses each have a little canal that leads into the nose to allow it to drain, but sometimes these little canals can get blocked or inflamed enough that anything inside the sinuses can't drain properly. So when that happens, you have sinusitis.
If this condition happens fairly often, we can go in and help correct that condition by opening up the little canals, opening up the passageways between the sinus and the nose itself to allow them to drain easier. And as you can see here, we've taken some of these little curves and little folds here in the between the sinuses and the nose, cut that out, open that up, and allowed for a lot better drainage. Now sometimes this can be done through the nose, through the nares themselves, but often getting especially to this maxillary sinus, which is right here. If you put your finger here, you feel your... Temporal process, this little cheekbone where it comes down just above the teeth, there's a little indent there right under that little indentation between your cheekbone and your teeth is where you'll find the maxillary sinus.
And sometimes the best way to get to that maxillary sinus is to go through the maxillary bone right in this area. But going right through the skin is probably going to leave a little bit of a scar. So we're going to take a slightly different approach.
This procedure is called a Caldwell-Luke. procedure. Now in this case we're going to go through the maxillary bone right above the alveolar process.
Now the alveolar process is the little protrusion that holds the teeth in place. So we're going to go just above the teeth into the maxillary sinus. Again this procedure is called a Caldwell-Luke procedure. But if we're working on sinuses a little bit higher in the skull, we can again enter through the nares, the openings of the nose.
and do something called a functional endoscopic sinus surgery, or a FESS, F-E-S-S. And as you can see, there's endoscopic is in the name. So endoscopic means that little camera, the little tube with the camera on it, a little light source we're going to insert in there to guide us and help us do the procedure endoscopically.
A little bit lower in the skull, we come to the throat. And let's take a look at some of the anatomy of the throat. The high class term for the throat is the pharynx.
And the throat is actually made up of three sections. The pharynx is in three sections. We have the nasopharynx, which is near the nose. We have the oropharynx, which is near the mouth.
And then we have the laryngopharynx or the hypopharynx, which is the lower pharynx of the throat. There are two tubes that run down from the pharynx into our chest. The front tube or the anterior tube is the trachea.
That's what's going to carry air into our lungs. The back tube or the posterior tube is the esophagus, and that's what carries food and water down to our stomach. To help control traffic through these different tubes, we have the epiglottis, which is a piece of tissue covering the top of the trachea that opens and closes as we breathe versus when we eat.
Just below the epiglottis, we have our larynx, which is the voice box, which contains our vocal cords. Around the pharynx or the throat, we have lymphatic tissue. Now, lymphatic tissue helps to filter fluid that surrounds our cells as it flows back into the bloodstream.
And as you can imagine, our mouth and our throat come into contact with a whole bunch of different germs that we don't want to get into our bloodstream. And that's where this lymphatic tissue comes into play. It filters that stuff out. The special name for this lymphatic tissue around our pharynx, around our throat, is tonsils. And we have three different types.
We have pharyngeal tonsil, otherwise known as the adenoids. And this is up behind the uvula and the soft palate towards the nasopharynx. On the sides of our throat, we have the palatine tonsils. These are the ones that you often see swell up when somebody gets a sore throat.
And then at the back of our tongue, we have the lingual tonsils. Lingual meaning tongue. So we have the lingual tonsils back there.
Now, any or all of these tonsils can become inflamed. And if that happens a lot, we can actually go in and surgically remove those tonsils. So the first throat surgery that we're going to discuss is the tonsillectomy. In this case, ectomy, meaning removal.
In this case, we're removing a tonsil. And you can see that we've done that here. We've removed one of the palatine tonsils.
If we have to remove the adenoids, the pharyngeal tonsils, which are again located at the back of the nasal cavity or the nasopharynx. We're going to use a little mirror to see what we're doing. And then we're going to use something possibly like a adenoid curette, which has a blade on the inside that's going to scrape around the back of the throat and remove that tonsil. We can also use some forms of cautery, which can burn away that tissue.
Now again, there are three different types of tonsils, our pharyngeal, palatine, and lingual tonsils. But... don't get these confused with the salivary glands, of which, again, there are also three, and they also have kind of similar sounding names. So salivary glands, this is the glands that produce saliva when we eat.
We have in the back the parotid gland, we have the submandibular gland, and then we have the sublingual gland, the sublingual one being under the tongue, submandibular being under the mandible, the bone, and the parotid ones being the large ones. sort of on the side of the face, just in front of the ear. So if you see questions on the test, don't confuse the three tonsils with the three salivary glands. With the parotid gland especially, you can have some problems such as a tumor may grow, there may be some inflammation that happens on a continuous basis, or the parotid gland could even form stones in there that can cause some problems, and in which case we're going to have to go in and remove some of these tissues. So a parotidectomy involves removing part or all of the parotid gland.
parotid gland, the large salivary gland just in front of the ear. But this gets a little tricky. This is a tricky surgery because the facial nerve, cranial nerve number seven, runs right through this area and it spreads out across the face, providing sensory information back to the brain.
So as we do this parotidectomy, we're going to be very careful not to damage those nerves. And we're usually going to use a nerve stimulator to touch. One point to a next point to find that nerve before we cut some tissue away to make sure we're not cutting the nerve.
A uvulopalatopharyngeoplasty or UPPP. In this case, we're talking about a plasty or a reconstruction of the uvula, the little piece that hangs down in the back of your throat, the palato, the palate, the soft palate, which is just above the uvula, and the pharyngeo, the part of the throat. So we're going to do a reconstruction or a modification of the tissues in this area.
Now the reason we might do a UPPP is because these tissues, sometimes at night, can cause blockages of the airway and cause difficulty sleeping. It causes a condition called sleep apnea, where the patient stops breathing for a moment because the airway is blocked, and they sort of wake up and sort of choke a little bit until they start breathing again and then fall back to sleep. As this happens over and over, you can imagine the patient's going to have trouble sleeping throughout the night if they're constantly waking up just to breathe.
So one way of fixing this is to do a UPPP in which case we're going to go in and remove some of that tissue. And here you can see some of that tissue removed. The uvula and part of the soft palate has been removed. If a patient can't breathe through their pharynx, sometimes we have to bypass that.
We're going to do that with a tracheotomy. Again, otomy, O, means an opening in the trachea. So we're going to create an opening in the trachea to allow air to pass directly to the outside. This usually involves inserting a special tube that has a little bubble inside that you then inflate that bubble to seal off the trachea, forcing the air to flow through the tube rather than into the throat.
Sometimes there can be a growth or a tumor in the larynx themselves, and we're going to do a laryngectomy. We're going to remove part of the larynx. When this happens, we're again creating that opening in the throat so that the trachea feeds directly to the outside of the body.
And in this case, it's going to be a permanent opening, and this is going to be called a stoma. Because we've removed the larynx, the patient's going to have great difficulty speaking, and they often use an assistive device to help them with that. If the tumor metastasizes, if it really spreads throughout the pharyngeal area, we may have to step up and do something called a radical neck dissection, in which case we're taking part or all of the tissue in and around the pharynx, in and around the neck, away in order to remove any of those cancerous cells. One important joint that can often give some patients problem is the temporomandibular joint. Now this is the joint between the temporal bone and the mandible, which is the chin bone here.
As you move your mouth up and down as you speak or eat, this is the joint that articulates, the temporomandibular joint, otherwise known as the TMJ. Now when we get to the ortho chapter, we're going to be talking about joints a whole lot. And one of the procedures that we're going to be doing in several joints throughout the body is an arthroscopy, where we use a little scope, insert it, and look around and maybe do some modifications inside the joint.
In this case, we're going to be doing the arthroscopy to the TMJ joint right here on the side of the face. Again, we're going to insert a camera, light source, and then our instruments through another hole and help to modify, maybe clean out, maybe fix up some of the tissues. that may be in this area. Sometimes this may involve just flushing the area with some fluids or maybe sculpting the bone and sculpting the joint in a little way that makes it open and close more easily. So that's a quick look at some of the ENT procedures that you might be assisting with.
I hope this gives you a little bit of better context as you go into your full ENT lecture.