1. Common ENT Operations. Tracheotomy. Laryngotomy (cricothyroidotomy). Tonsillectomy. Adenoidectomy

2. Definition: Creation of a surgical opening between the trachea and skin surface.  Temporary (tracheotomy): just opening the anterior wall of the trachea to the skin.  Permanent ( tracheostomy) : opening the anterior wall of trachea and suturing the mucosa of trachea with the skin, example; following total laryngectomy. Tracheostomy timing: Emergent ( also known as slash trach): indicated in emergency airway distress when impending death of a patient exist. Urgent (awake): indicated in a patient with respiratory distress and needs immediate surgical intervention. This is best done in a controlled environment ( intensive care unit or operating room) while using local anesthesia on an awake patient. Elective: mostly done in the intubated patients and in patients undergoing extensive head and neck procedures to facilitate airway control during the postoperative recovery period. Tracheotomy

3. Indications : 1- Relief of up. airway obstruction : due to the following causes: a- congenital bilateral choanal atresia laryngeal web or cyst subglottic stenosis tracheo-esophageal anomalies. b- traumatic external: blunt neck trauma as RTA, sport injuries, assault penetrating neck injuries as missiles, blasts, stabs. internal: inhalation of steam or irritating fumes foreign bodies and chemicals c- infection acute laryngotracheobrondhitis, acute epiglottitis diphtheria, ludwig’s angina d- tumors benign and malignant tumors of the tongue, pharynx, larynx, upper trachea and thyroid gland. e- bilateral vocal cord palsy after thyroidectomy bulbar palsy f- allergy : angioneurotic edema

4. 2- Protection of tracheobronchial tree : aspiration can be done easily in conditions leading to: 1- inhalation of saliva, food, blood or gastric contents 2- stagnation of bronchial secretions These Conditions include: a- coma: due to any cause ( head injury, CVA, drug overdose….etc) b- poliomyelitis c- tetanus d- myasthenia gravis e- burns of the face and neck f- multiple fractures of the mandible

5. 3- Treatment of conditions leading to respiratory insufficiency: Any of the diseases mentioned above in (1) and (2) might cause respiratory insufficiency. It may also result from: chronic bronchitis emphysema severe chest injury ( flail chest) 4- Elective For major operations of the mouth, pharynx and larynx to facilitate the surgery and the postoperative recovery.

6. Surgical technique : Anesthesia : general or local (lidocaine infiltration) Position: head extended over a small sandbag under the neck Incision: midline vertical between the cricoid and suprasternal notch or horizontal ( in elective cases) 2 cm below the cricoid. Separation of strap muscles: in the midline by scissor. Thyroid isthmus: divided and ligated or retracted (upward or downward). Trachea exposed and opened: between 2 nd -4 th tracheal rings by taking a circular cut out window from the anterior tracheal wall or making a superiorly based flap or just making vertical incision without cartilage removal ( in children). The first tracheal ring should not be disturbed. Insertion of tube: either plastic (portex) or metallic (silver). Closure of wound: after ligation or electrical cautery of bleeding points the wound is loosely closed for fear of emphysema or of making reinsertion of the displaced tube more difficult (if closed tightly).

7.  Tracheotomy tubes: 1- metal (silver) inner and outer tubes longer half life more traumatic without cuff can be used with laser but not radiotherapy 2- plastic tube (portex) Only one tube (usual types) Shorter half life More comfortable and less traumatic With or without cuff Used with radiotherapy but not laser

8.  Postoperative care: 1- position: sitting or semi-sitting. 2- suction : applied regularly passing a sterile catheter into the trachea. 3- humidification :humidifier or moisturized gauze to prevent crustation and tube obstruction. 4- chart of vital signs 5- observation of the area: for hematoma or emphysema. 6- dressing: changed regularly once or twice daily. 7- changing the tube: better kept as long as possible unless there is tube obstruction. It is advised to keep it at least 72 hours before the first change.  Physiological changes and effects of tracheotomy: 1- bypass upper airway obstruction. 2- reduce the dead space area by up to 50%. 3- reduce airway resistance. 4- allow for clearance and suction of lower respiratory tract secretions. 5- allow for assisted ventilation ( mechanical ventilation).

9. Complications of tracheotomy  1- Immediate : during the operation or immediately after: a- hemorrhage : from the skin, muscles or thyroid gland; controlled by packing, electrical cautery or by ligation. b- air embolism: the large veins of the neck (negative pressure vessels) if opened inadvertently might suck air and result in air embolism. c- apnea: due to rapid washout of the Co2 from the blood following tracheotomy, since the Co2 is the main stimulus for the respiratory center in the brain, sudden or rapid decline in the Co2 level in the blood might results in suppression of the respiratory center. This can be avoided by inhalation of O2 mixed with Co2 ( carbogen). d- damage to adjacent structures: innominate artery or pleura of the lung dome ( especially in children). e- cardiac arrest: due to hyperkalemia from tissue damage or acid- base imbalance. f- Complications of GA.

10. 2- Intermediate: during patient stay at the hospital: a- Dislodgement or displacement of the tube: accidentally or by coughing, retching or vomiting. This is prevented by suturing the tube to the skin and use of special tape fixed to the tube and wrapped around the neck. b- Obstruction of the tube: due accumulation of crustation of secretions inside the tube. Prevented by humidification and repeated sterile suction. c- Surgical emphysema: due to extensive subcutaneous dissection, large tracheotomy opening, small tracheotomy tube or tube obstruction. Usually self-limiting. d- Pneumothorax and pneumomediastinum: if there is damage to the pleura of the lung. More common in children. e- Infection of the stoma: daily dressing, local antibiotics and tube replacement reduce the incidence of infection and bacterial biofilm formation f- Fistula : between the trachea and innominate artery resulting in bleeding from the stoma which could be first only minor (sentinel bleeding) followed by massive bleeding 3 days to 3 weeks later. Or between the trachea and esophagus (tracheo-esophageal fistula) resulting in dysphagia and aspiration.

11.  3- Late : when the patient has gone home: a- stenosis: narrowing due to stenosis at the level of the stoma or in the subglottis due to granulation tissue formation caused by trauma from the tube or by local infection. Treatment by dilatation or surgery. b- persistent tracheo-cutaneous fistula: closure of the tracheotomy called weaning or decannulation done by gradual reduction of the tube size for several days at the hospital and then removal of the tube( if the patient can tolerate). After tube removal the wound will close spontaneously by secondary intention without wound suturing in vast majority of cases. Only rarely the wound will not close after tube removal resulting in persistent tracheo- cutaneous fistula which should be closed surgically under GA.

12. Opening through the cricothyroid membrane.  Indications : sudden laryngeal obstruction when facilities or experience for tracheotomy are not available, impaction of a foreign body in the larynx is the commonest indication.  Surgical technique: It is an emergency done without anesthesia using any sharp instrument as a knife and making a transverse incision through the cricothyroid membrane, the incision is then deepened followed by insertion of a tube. Wide bore cannula can be used instead of the incision and tube insertion. The membrane is immediately subcutaneous in location with no overlying large veins, muscles or fascial layers allowing easy access. Laryngotomy provides relief for only short period of time until the patient is transferred to the hospital where facilities and experience are available. Laryngotomy (cricothyroidotomy)

14. Tonsillectomy is the commonest elective operation performed all over the world. Anatomy: Waldeyer’s ring consists of the nasopharyngeal tonsil, lateral pharyngeal bands, palatine tonsils and lingual tonsils. It is the palatine tonsils to which the term tonsils is applied. The palatine tonsils (right and left) are invaginated on the medial surface by crypts (6-20 in number) lined with squamous mucosa. Epithelial debris collecting in these crypts and mixed with bacteria from the oral cavity cause chronic inflammation and when the crypts become obstructed, tonsilloliths might develop which are often malodorous. The palatine tonsil is lined with a capsule on its deep surface and is separated by loose areolar tissue from the underlying superior constrictor muscle. The blood supply to the palatine tonsils includes branches from: 1- ascending pharyngeal a. 2- ascending palatine a. 3- lingual a. 4- facial a. (main blood supply to the palatine tonsils) 5- descending palatine a. Venous drainage ultimately into the internal jugular vein. Tonsillectomy and Adenoidectomy

15. The palatine tonsils drain mainly into the upper deep jugular lymph nodes They are located in a fossa between folds of palatal musculature known as the anterior and posterior pillars ( palatoglossus and palatopharyngeus muscles respectively). The palatine tonsil (adenoid) is a single midline structure situated at the junction of the roof and posterior wall of the nasopharynx. It is lined by columnar (respiratory) epithelium and there is no capsule on its deep surface. The blood supply to the adenoid is primarily from the ascending pharyngeal artery. Venous drainage ultimately into the internal jugular vein. Lymph drains into the deep jugular lymph nodes either directly or through the retropharyngeal lymph node.

16.  Indications of tonsillectomy: 1- recurrent tonsillitis: 4 or more attacks of genuine tonsillitis per year for 2-3 years. the decision to perform tonsillectomy may be based on the amount of time that the patient is non-productive ( school or work absence) 2- peritonsillar abscess(quinsy): recurrent quinsy is an absolute indication while single attack is a relative indication. 3- respiratory obstruction: hypertrophied tonsils causing sleep disorders or dental malocclusion 4- suspicion of malignancy: unilateral tonsillar hypertrophy or ulceration on the tonsil. The tonsil is removed for biopsy (excisional). 5- other indications: approach to glossopharyngeal nerve (Eagle’s syndrome), recurrent otitis media, chronic inflammation causing foul breath or taste ( no response to medical treatment)  Indications of adenoidectomy: 1- airway obstruction: hypertrophied nasopharyngeal tonsil causing sleep disorders 2- recurrent suppurative otitis media ( no response to medical treatment) 3- otitis media with effusion ( no response to medical treatment)

17.  Contraindications of adenotonsillectomy: relative contraindications 1- bleeding disorders: as hemophilia,thrombocytopenia. Should be corrected first. 2- recent infection of the tonsil or adenoid: the surgery should be postponed for 2 weeks because of increased risk of bleeding. 3- clef palate: is a contraindication of adenoidectomy because it might results in velo-pharyngeal incompetence and hypernasal speech. 4- general contraindications to GA: as anemia, uncontrolled DM or hypertension.  Preparation for surgery and Investigations : History: full including; number of genuine attacks per year, school or work absence due to the infection history of bleeding disorders. Examination: local and general Investigations: 1- full blood count 2- bleeding profile: bleeding time clotting time prothrombine time (PT) partial thromboplastine time (PTT) international normalization ratio (INR) 3- general urine examination 4- chest x-ray

18.  Surgical technique : Tonsillectomy: 1- Cold dissection technique: using sharp dissection by special instrument (dissector). 2- Diathermy: use of electrical cautery to dissect the tonsils. Might cause thermal damage to the surrounding structures and associated with increased risks of pain and infection postop. 3- Laser : diod, argon, co2 and Nd-YAG. (similar effect postop.to diathermy). Useful in patients with bleeding tendency. 4- Coblation: use of bipolar current to create a plasma field which can results in dissociation of organic molecules. Creation of this field occurs at low temperature (60-70 c) which is less than that of electrical diathermy or radiofrequency. The decreased temperature will diminish surrounding tissue edema with less pain and rapid return to regular diet and normal activity post- operatively 5- harmonic scalpel: ultrasonic technology is used to cut and coagulate tissue also at low temperature similar to coblation. 6- Radiofrequency: heating the target tissue by placing an electrode submucosally. This electrode generates radiofrequency which cause tissue heating, thus shrinkage tissue volume while leaving intact overlying mucous membrane. Adenoidectomy : Done by curation using special curette passed through the oral cavity into the nasopharynx under GA. Alternatively the adenoid is removed by suction electrocautery or the use of powered instrument ( micro-debrider).

19. Post-operative care: 1- position: lateral position with the head down 2- chart of vital signs 3- diet: in the 1 st 24 hour soft cold diet as ice cream, cold milk and juice. After 24 hour encourage normal diet. 4- analgesia : paracetamol or narcotics. Non-steroidals (NSAIDs) should be used with caution. 5- antibiotics: postoperative antibiotic use is controversial. Prophylactic perioperative antibiotics should be used in patients with cardiac abnormality. 6- Discharge: time of discharge from the hospital is controversial, in general patients who develop complications postoperatively, or younger than 2 years or those with obstructive sleep apnea should be kept at the hospital overnight otherwise patients can be discharged the same day.

20. 1- Per-operative ( during the operation) A- Hemorrhage: primary hemorrhage occurs at the time of the operation up to 1 hour postoperatively. Careful gentle dissection and adequate homeostasis by silk ligature or electric cautery should overcome this complication. Recent infection,previous quinsy and severe scarring are the factors which increase the rate and severity of hemorrhage. B- Trauma to the adjacent structures: teeth, gums, tongue and palate might happen. C- Anesthesia complications: respiratory or cardiovascular. Complications of Adenotonsillectomy

21. 2-Post-operative: Early : A- Hemorrhage : postoperative hemorrhage is of 2 types Reactionary and Secondary. Reactionary h. occurs from 1 st to 24 hours postoperatively; it is due to slipped ligature or dislodgement of blood clot from excessive venous pressure induced by cough or retching. Secondary h. occurs any time after 24 hours postoperatively, classically at 6-8 days. It is usually due to infection and mild in severity. Management of postoperative hemorrhage: hospital admission with close observation. prepare cross matched blood and blood transfusion as necessary As a rule all children with hemorrhage even if it is minor should be returned back to operating theater to stop the bleeding under GA by silk ligature electric cautery. In adults if it is minor bleeding : conservative treatment If bleeding continues or severe : return back to the operating theater and control hemorrhage under GA. So there are 3 types of hemorrhage following tonsillectomy or adenoidectomy: primary, reactionary and secondary.

22. B- Infection : results in pain, fever and secondary hemorrhage. Usually it is mild and treated conservatively with antibiotics. C- Pulmonary complications: as atelactasis, pneumonia. D- Subacute bacterial endocarditis (SBE): Tonsillectomy leads to transient bacteremia and if the patient has abnormal heart valves, SBE may complicate the operation. E- other complications : as pain, nausea and vomiting. Late: A- scarring: of the pharyngeal mucosa and palate which could affect the voice. B- remnant : incomplete removal of the tonsil or adenoid will leave a remnant which might re-grow again.