Presentation on theme: "New York-Presbyterian Hospital/Weill Cornell Medical Center"— Presentation transcript:
1 New York-Presbyterian Hospital/Weill Cornell Medical Center April 26-28, 2013New York-Presbyterian Hospital/Weill Cornell Medical CenterENT ProceduresJason Fowler, MPAS, PA-CJose C. Mercado, MMS, PA-C
2 ENT Procedures Workshop ◄ Instruction ● Demonstration ● Practice ►Basic instructionClear demonstrationHands-on doing!Exchange of ideasLearn by DoingRemoval Foreign Body (Nose)Control Anterior EpistaxisControl Posterior EpistaxisFine Needle AspirationPeritonsillar AbscessTracheostomy Care
3 IntroductionThere are multiple methods and techniques available to successfully complete all the topics presented in this workshop. Some are based on patient request, available equipment or supervising physician’s preference.The goal of this workshop is to correctly demonstrate the most common methods and give participants time for hands on training.
4 ENT Procedures Workshop Learning ObjectivesDiscuss indications for and practice removal nasal foreign body.Discuss indications for and practice control anterior epistaxis.Discuss indications for and practice control posterior epistaxis.Discuss indications for and practice fine needle aspiration.Discuss indications for and practice peritonsillar abscess drainage.Discuss indications for tracheostomy and practice tracheostomy care.
5 Removal Foreign Body (Nose) Purulent unilateral nasal discharge, especially in childrenUsually lodge on the floor of anterior or middle thirdFigure. A: Fiberoptic nasal endoscopy shows the mass in the left anterior nasal cavity.B: Coronal CT shows the area of attenuation in the left inferior turbinate.C: Photograph shows the broken mass.D: Following removal of the mass, the passageway is clear.Mercado, JC, Goldberg SG, Recurrent purulent rhinorrhea in an otherwise healthy woman Ear Nose Throat J Jun;83(6):381-2
6 Removal Foreign Body (Nose) Good visualization: headlamp & nasal speculumAlligator forceps should be used to remove cloth, cotton, or paperOther hard FB are more easily grasped using bayonet forceps or Kelly clamps, or they may be rolled out by getting behind it using an ear curette, single skin hook, or right angle ear hookPractice mannequins available to practice removal of nasal foreign bodies technique.
9 Anterior vs Posterior Epistaxis Kiesslebach’s Plexus or Little’s Area is most common site of anterior nosebleeds. Woodruff’s Plexus is most common site for posterior nose bleeds and may represent a lesion. Sphenopalatine artery is generally the source of severe posterior nosebleeds. Posterior more difficult to control will be discussed in Advanced ENT Procedures Workshop.
10 Etiology of Epistaxis Local Systemic Trauma /Nose picking or blowing / surgeryDry air / IrritantsTopical medications (steroids)Foreign bodyTumorSystemicBleeding disordersHereditary hemorrhagic telangiectasiaDrugs (anticoagulants)Hypertension
24 Anterior vs Posterior Epistaxis Kiesslebach’s Plexus or Little’s Area is most common site of anterior nosebleeds.Woodruff’s Plexus is most common site for posterior nose bleeds and may represent a lesion.Sphenopalatine artery is generally the source of severe posterior nosebleeds.Posterior tend to be more difficult to control and may suggest an underlying etiology.
25 Etiology of Epistaxis Local Systemic Trauma (Nose picking or blowing) Dry air / IrritantsTopical medications (steroids)Foreign bodyTumor / polypSurgerySystemicHypertensionCoagulopathiesHereditary hemorrhagic telangiectasiaDrugs (anticoagulants)
26 Control Posterior Epistaxis Control HypertensionIdentify Coagulopathy –Treat with FFP, transfusions, etcPT, PTT, INRCoumadin toxicity - Vitamin KPosterior PackingEndoscopic CauterizationArterial Embolization (Interventional Radiology)
28 1 2 3 Rapid Rhino® 900 for Posterior Epistaxis Thoroughly soak in sterile water for 30 seconds.Insert Rapid Rhino into the patient’s nostril parallel to the septal floor, or following along the superior aspect of the hard palate, until the blue indicator ring is inside the opening of the nostril.Using a 20 cc syringe, slowly inflate the posterior (green stripe) balloon first with air only inside the patient’s nose.
29 4 5 6 Rapid Rhino® 900 for Posterior Epistaxis Inflate second balloon with air.Allow the patient to sit for minutes prior to discharge. Swelling in the nasal anatomy will reduce and the balloons may need to be inflated more to avoid movement of the device. Don’t forget prophylaxis antibiotics!To remove packing, deflate balloons hours later.
30 Additional Treatments Image on right is a 63-year-old woman with epistaxis refractory to nasal packing. Anteroposterior angiogram shows injection in right distal internal maxillary artery. Medial or septal branches supply septum (straight arrow), and lateral branches supply turbinates (curved arrow).Endoscopic CauterizationB. Ghorayeb, MDArterial EmbolizationKoh E et al. AJR 2000;174:
34 AnesthesiaFor superficial aspirates, clean technique suffices for cleansing of the skin surface.Local anesthetic may or may not be used. If more than two or three attempts are anticipated, this is recommended.However, be certain not to contaminate the lesion with a large volume of anesthetic.Also, make attempts not to directly interfere with the ability to palpate and localize the lesion.For deep aspirates, sterile technique is required for cleansing of the skin and local anesthetic is usually required.
40 Fine Needle Aspiration Aspiration techniques vary widely based on personal preference, and specific clinical circumstances. Goal is to collect adequate cellular material for cytologic evaluation.Practice mannequins available to palpate and practice technique.
45 Peritonsillar Abscess Management optionsNeedle aspirationIncision and DrainageQuinsy tonsillectomyChoice will depend on site and location of abscess. Smaller, deep abscess are sometimes easier to reach with large bore needle.Both have similar success rates (Needle Aspiration 90-95% vs I and D %)
46 Peritonsillar Abscess Aim medial. Critical area is lateral pharyngeal space which connects to all other spces.
51 Clinical Consensus Statement: Tracheostomy Care Clinical consensus statement (CCS) Aims to improve care for pediatric and adult patient with a tracheostomy tube.Approaches to tracheostomy care are currently inconsistent among clinicians and between different institutions.The goal is to reduce variations in practice when managing patient with a tracheostomy to minimize complications.Variations in care and management of patient with a tracheostomy exist between hospitals, inpatient and outpatient facilities, and in the emergency room.Presently, the current literature does not support the development of clinical practice guidelines but favors a consensus of expertise.
53 Selection of Tracheostomy Tracheostomy tubes come in different sizes and different materials.Two types of tracheostomy tubes commonly used are Polyvinyl chloride tracheostomy tubes (Shiley) and Silicone (Bivona). Shiley tubes are slightly flexible and Bivona are the most flexible.Both Shiley and Bivona tubes come standard with a universal adapter for ventilation. In double cannula tubes, the inner cannula is inserted and locked in place after the obturator is removed.The inner cannula can be removed briefly for cleaning. The outer tube is secured to the paitent. Single cannula tubes are often used in children and do not have an inner cannula.The Tracheostomy Care portion of the workshop will ONLY focus on dealing with complications associated with ;ObstructionDecannulation (Accidental & Intentional)BleedingLeaksChanging tracheostomy
54 Selection of Tracheostomy Fenestrated tracheostomy tubes facilitate speech by allowing better translaryngeal air flow. Some clinicians believe that fenestrated tubes also aid in the clearance of secretions. Other clinicians feel that these tubes promote the development of granulation tissue along the tracheal wall at the level of the fenestrations. Since there is little scientific data to support either opinion, it is up to surgeon’s preference.Cuffed tubes have a balloon at the distal end of the tube and allow for mechanical ventilation.Uncuffed tubes are generally preferred in children. Except when requiring ventilation with high pressures, requiring ventilation only at night, or with chronic translaryngeal aspiration.
57 LeaksA low-pressure, high volume cuff is preferred to avoid unnecessary injury to the tracheal mucosa such as tracheal malacia.Check cuff pressure first.Consider changing to a longer tracheostomy tube.Monitor cuff pressure on a regular basis.Shiley® Tube SizeLeak Test Volume1020cc817cc614cc411cc
58 Bleeding Local bleeding Controlled with Granulation tissue Superficial bleeding from mucosaSmall vesselsControlled withPressure dressingGelfoamChemical cauterization
59 BleedingBut for anything more than oozing. Must rule out tracheo-innominate artery fistula (TIAF).Caused include;Low tracheostomyHigh innominate arteryCuff overinflationInfection
60 Bleeding TIAF may cause massive hemorrhage in 0.7% of tracheotomies. 2/3 occur in first 3 weeks after tracheostomyLong-term intubation and ventilation.Cuffed or uncuffed tube.
61 Changing Tracheostomy In the absence of aspiration, tracheostomy tube cuffs should be deflated when the patient no longer requires mechanical ventilation.A patient initial tracheostomy tube should normally be replaced within days.The Panel agreed an experienced physician should ideally be present for the first tube change, although there are was recognition that in some facilities, this may not be feasible and thus performed by an experienced advanced practice provider (APP) with immediate physician backup available.In an emergency, a dislodged, mature tracheostomy tube should be replaced with the same size or a size smaller tracheostomy tube. If those are not available for could not be inserted, then an appropriately sized endotracheal tube should be placed through the wound into the trachea. In a patient in whom a tube could not be replaced, resulting in hypoxia or concern for eventual loss of airway, they should undergo oral tracheal intubation or immediate surgical revision tracheostomy.
62 Downsizing, capping and decannulation When the adult patient is in the hospital and;Does not require mechanical ventilationIndication for tracheotomy has resolvedPatient tolerates breathing through the tracheotomy tube with the cuff deflated.Breathing with a cuffless #6 Shiley tube is checked (smaller patients, a cuffless #4 Shiley tube is placed)Patient tolerates capped tracheostomy with a red button.If the patient is stable (normal oxygen and CO2) for 24 – 48 hours with the trach plugged, the tube will be removed by a qualified physician or mid-level provider, and the stoma will be allowed to close.Downsizing, capping and decannulation62
64 Decannulation When the patient succeeds at decannulation sequence, 1. Wound margins should heal by secondary intention, with initial wound co-apting in 5 to 7 days (unless wound was created with a fenestration technique) 2. New epithelial cells grow across wound in 7 to 10 days. No leak of air from the wound at this time. 3. If wound does not heal, then wound may be closed surgically, by separating trachea from the skin, and closing the wounds in layers. 4. If scar appearance is not acceptable, wound may be closed in a transverse incision across the lower neck with a plastic closure.64
68 Clinical Consensus Statement Tracheostomy tube should be changed using a clean technique. A sterile technique is not necessary and does not lead to a reduction in impaction.Plastic tracheostomy tube should be used among pediatric and adult patients for initial tube placement.Tracheostomy tube ties it should be used unless the patient recently underwent local or free flap reconstructive surgery or other major neck surgery.No patient should be discharged with tracheostomy tube sutured in place. Any suture securing a tracheostomy should be removed during first tube change.Stoma and tracheostomy tube should be suctioned when there is evidence of visual or audible secretions in the airway, suspected airway obstruction, and whether tube is changed or deflated.