Transcript Introduction - Society of PAs in ORL-HNS

April 26-28, 2013
New York-Presbyterian
Hospital/Weill Cornell
Medical Center
ENT Procedures
Jason Fowler, MPAS, PA-C
Jose C. Mercado, MMS, PA-C
ENT Procedures Workshop
Basic instruction
Clear demonstration
Hands-on doing!
Removal Foreign Body
(Nose)
Control Anterior Epistaxis
Control Posterior Epistaxis
Fine Needle Aspiration
Peritonsillar Abscess
Tracheostomy Care
Introduction
There are multiple methods and techniques
available to successfully complete all the
topics presented in this workshop. Some are
based on patient request, available
equipment or supervising physician’s
preference.
The goal of this workshop is to correctly
demonstrate the most common methods
and give participants time for hands on
training.
ENT Procedures Workshop
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Learning Objectives
Discuss indications for and practice removal nasal foreign
body.
Discuss indications for and practice control anterior
epistaxis.
Discuss indications for and practice control posterior
epistaxis.
Discuss indications for and practice fine needle aspiration.
Discuss indications for and practice peritonsillar abscess
drainage.
Discuss indications for tracheostomy and practice
tracheostomy care.
Removal Foreign Body (Nose)
• Purulent unilateral
nasal discharge,
especially in children
• Usually lodge on the
floor of anterior or
middle third
Figure. A: Fiberoptic nasal endoscopy shows the
mass in the left anterior nasal cavity.
B: Coronal CT shows the area of attenuation in
the left inferior turbinate.
C: Photograph shows the broken mass.
D: Following removal of the mass, the
passageway is clear.
Mercado, JC, Goldberg SG, Recurrent purulent rhinorrhea in an otherwise healthy woman Ear Nose Throat J. 2004
Jun;83(6):381-2
Removal Foreign Body (Nose)
Good visualization:
headlamp & nasal
speculum
Alligator forceps should be
used to remove cloth,
cotton, or paper
Other hard FB are more
easily grasped using
bayonet forceps or Kelly
clamps, or they may be
rolled out by getting
behind it using an ear
curette, single skin hook,
or right angle ear hook
Practice mannequins
available to practice
removal of nasal foreign
bodies technique.
Control Anterior Epistaxis
Control Anterior Epistaxis
Control anterior epistaxis in
office.
Mercado 2011 ©
Apply direct manual
pressure for at least 10
minutes
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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.
Etiology of Epistaxis
Local
Systemic
Trauma /Nose picking
or blowing / surgery
Dry air / Irritants
Topical medications
(steroids)
Foreign body
Tumor
Bleeding disorders
Hereditary hemorrhagic
telangiectasia
Drugs (anticoagulants)
Hypertension
Direct Manual Pressure
NO
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NO
YES
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Control Anterior Epistaxis
Spray or apply
topical anesthetic
with decongestant.
Reapply direct
manual pressure
an additional 10
minutes.
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Control Anterior Epistaxis
Once bleeding has
subsided, identify
site of nosebleed.
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Control Anterior Epistaxis
Control bleeding with
silver nitrate
cauterization. (start
from outside in)
Caution bilateral
cauterization as may
result in septal
perforation.
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Control Anterior Epistaxis
Lubricate naris with Vaseline
or Neosporin ointment.
Let sit for 10-15 minutes to
ensure hemostasis is
achieved.
Keep cotton in nares for at
least 1 hour to prevent
staining.
Avoid sneezing, forceful nose
blowing, nose picking, etc.
Follow up 2 weeks as recauterization may be
necessary.
Post chemical cauterization stain day 1
Post chemical cauterization stain day 4
Mercado
2011 2011
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Mercado
Anterior Nasal Packing
Nasal packing
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Absorbable gelfoam
Vasaline guaze
Nasal tampon
Anterior packing
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Anterior Nasal Packing
Nasal packing
• Vaseline gauze – is
inserted along floor of
naris to form a tight
seal.
Anterior Nasal Packing
Nasal packing
• Nasal tampon –
expands in nasal
cavity to form a tight
seal.
• Do not allow
packing to moisten
until in position.
• Removal may cause
re-bleeding.
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Anterior Nasal Tampon
• Insert nasal
tampon
horizontally.
• Lubricate with
Neosporin but DO
NOT moisten!
• Secure ties to
cheek.
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Practice mannequins available to
practice anterior nasal packing
technique.
Anterior Nasal Packing
Anterior nasal packing
– Easy to insert and
remove due to selflubricating hydrocolloid
fabric and ultra-low
profile.
– Packing quickly conforms
to nasal anatomy and
provides gentle and even
compression to areas of
epistaxis.
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Anterior Nasal Packing
• Soak dressing to hydrate
Gel Knit hydrocolloid
fabric in sterile water for
30 seconds.
• Insert Rapid Rhino
horizontally.
• Inflate balloon only with
air.
• Tape pilot cuff to side of
face.
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How NOT to pack a nose!!!
Control Posterior Epistaxis
Anterior vs 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.
Etiology of Epistaxis
Local
Systemic
Trauma (Nose picking
or blowing)
Dry air / Irritants
Topical medications
(steroids)
Foreign body
Tumor / polyp
Surgery
Hypertension
Coagulopathies
Hereditary hemorrhagic
telangiectasia
Drugs (anticoagulants)
Control Posterior Epistaxis
• Control Hypertension
• Identify Coagulopathy –Treat with FFP,
transfusions, etc
– PT, PTT, INR
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Coumadin toxicity - Vitamin K
Posterior Packing
Endoscopic Cauterization
Arterial Embolization (Interventional Radiology)
Posterior Nasal Packing
• Topical anesthetic &
decongestant
• Posterior nasal
packing
– Foley catheter
– Double balloon
device
Rapid Rhino 900 for Posterior Epistaxis
®
1. Thoroughly soak in sterile water for 30 seconds.
2. Insert Rapid Rhino into the patient’s nostril parallel to the septal floor,
or following along the superior aspect of the hard palate, until the blue
indicator ring is inside the opening of the nostril.
3. Using a 20 cc syringe, slowly inflate the posterior (green stripe)
balloon first with air only inside the patient’s nose.
Rapid Rhino 900 for Posterior Epistaxis
®
4. Inflate second balloon with air.
5. Allow the patient to sit for 15-20 minutes prior to discharge. Swelling
in the nasal anatomy will reduce and the balloons may need to be
inflated more to avoid movement of the device. Don’t forget
prophylaxis antibiotics!
6. To remove packing, deflate balloons 24-72 hours later.
Additional Treatments
Endoscopic Cauterization
Arterial Embolization
B. Ghorayeb, MD
Koh E et al. AJR 2000;174:845-851
http://www.ghorayeb.com/EpistaxisPosteriorEndoscopicView.html
http://www.ajronline.org/content/174/3/845.full
Control Posterior Epistaxis
Practice mannequins
available to practice
posterior nasal packing
technique.
Mercado 2011 ©
Fine Needle Aspiration
Site Selection
Common sites include thyroid and parotid
glands as well as lymph nodes.
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Anesthesia
• For superficial aspirates, clean technique suffices for
cleansing of the skin surface.
• Local anesthetic may or may not be used. If more than
two or three attempts are anticipated, this is
recommended.
• However, be certain not to contaminate the lesion with a
large volume of anesthetic.
• Also, make attempts not to directly interfere with the
ability to palpate and localize the lesion.
• For deep aspirates, sterile technique is required for
cleansing of the skin and local anesthetic is usually
required.
Fine Needle Aspiration
• Use a 3, 5, 10 or 20 mL syringe. Use of a “Syringe Pistol” is optional.
• Needle should be at least 1 ½ inch or appropriate length and be 22 to
25 gauge.
• Single end label clear glass slides (for preparation of direct smears).
• Fixative to preserve fixed slides (either Cytology spray fixative,
Saccomanno fixative or 95% ethyl alcohol in coplin jar).
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Fine Needle Aspiration
Palpate and identify mass or lesion.
Clean topically with alcohol.
Stabilize the mass with non-dominant hand.
Insert needle through the skin with a quick motion.
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Fine Needle Aspiration
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Advance through the subcutaneous
tissue into the mass. Aim needle
toward the center of small masses
but toward the periphery of larger
masses as the center may be
necrotic.
A noticeable difference in the
consistency of the tissue should be
noted when the needle penetrates
the mass.
With the needle in the mass, the
needle tip should be moved in short
motions initially to loosen cells within
the mass.
Pull back on plunger to create
negative pressure.
Fowler 2011 ©
Fine Needle Aspiration
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Without releasing pressure, withdraw
the needle within the target slightly
then reinsert at a slightly different
angle.
Repeat maneuver several times
before complete withdrawal. May also
perform a corkscrew action before
withdrawal.
If blood or material appears in the hub
of the needle, the aspiration should be
stopped.
Release negative pressure before
withdrawing the needle, negative
pressure must be released to prevent
suction of the material into the barrel
of the syringe when the needle exits
the skin.
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Preparing Slides
Transfer specimen from needle hub
to slides.
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Gently and evenly spread specimen
between two slides before fixing. Allow to
air dry before closing slide holder.
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Fine Needle Aspiration
Aspiration techniques
vary widely based on
personal preference,
and specific clinical
circumstances.
Goal is to collect
adequate cellular
material for cytologic
evaluation.
Practice mannequins
available to palpate and
practice technique.
Peritonsillar Abscess
Peritonsillar Abscess
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History
Severe Odynophagia
Dysphagia
Physical
Fever
Unilateral edema
Hot Potato Voice
Elevated white count
(CBC)
CT Scan with contrast
Fowler 2011 ©
Peritonsillar Abscess
Strong clinical suspicion without obvious physical findings.
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Equipment needed
Hurricaine spray
Lidocaine w/ epi
Tongue Blade
Scalpel
Headlight
Suction setup
Long tonsil clamp
Culturette
Peritonsillar Abscess
• Management options
– Needle aspiration
– Incision and Drainage
– Quinsy tonsillectomy
• Choice will depend on site and location of
abscess. Smaller, deep abscess are sometimes
easier to reach with large bore needle.
• Both have similar success rates (Needle
Aspiration 90-95% vs I and D 90-100%)
Peritonsillar Abscess
Peritonsillar Abscess
Needle Aspiration
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Incision and Drainage
Incision & Drainage with #15 blade
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Blunt Disection with curved
hemostat
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Peritonsillar Abscess
Discharge instruction :
Penicillin based antibiotics
Oral prednisone
In-office follow up, possible tonsillectomy
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Practice mannequins available to simulate PTA and
practice needle aspiration technique.
Tracheostomy Care
Clinical Consensus Statement:
Tracheostomy Care
• Clinical consensus statement (CCS) Aims to improve care
for pediatric and adult patient with a tracheostomy tube.
• Approaches to tracheostomy care are currently inconsistent
among clinicians and between different institutions.
• The goal is to reduce variations in practice when managing
patient with a tracheostomy to minimize complications.
• Variations in care and management of patient with a
tracheostomy exist between hospitals, inpatient and
outpatient facilities, and in the emergency room.
• Presently, the current literature does not support the
development of clinical practice guidelines but favors a
consensus of expertise.
Selection of Tracheostomy
Tracheostomy tubes come in different sizes and different
materials.
Two types of tracheostomy tubes commonly used are
Polyvinyl chloride tracheostomy tubes (Shiley) and Silicone
(Bivona). Shiley tubes are slightly flexible and Bivona are
the most flexible.
Both Shiley and Bivona tubes come standard with a universal
adapter for ventilation. In double cannula tubes, the inner
cannula is inserted and locked in place after the obturator is
removed.
The inner cannula can be removed briefly for cleaning. The
outer tube is secured to the paitent. Single cannula tubes
are often used in children and do not have an inner cannula.
Selection of Tracheostomy
Fenestrated tracheostomy tubes facilitate speech by allowing better translaryngeal air flow. Some
clinicians believe that fenestrated tubes also aid in the clearance of secretions. Other clinicians feel
that these tubes promote the development of granulation tissue along the tracheal wall at the level of
the fenestrations. Since there is little scientific data to support either opinion, it is up to surgeon’s
preference.
Cuffed tubes have a balloon at the distal end of the tube and allow for mechanical ventilation.
Uncuffed tubes are generally preferred in children. Except when requiring ventilation with high
pressures, requiring ventilation only at night, or with chronic translaryngeal aspiration.
Obstruction
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6.
7.
8.
Position the patient’s head with a roll under the shoulders. Ensure that the outer opening of the tube is clear.
Check that the tube is in the proper location. It should be against the neck, and the obturator should not be in place.
If the patient has a fenestrated tube, remove the decannulation plug.
Give oxygen (over the tracheostomy tube), then looses secretions by placing up to 1 to 2 ml of normal saline into the tube.
Suction the tube with a suction catheter set to 100 mmHg or less. Insert the suction catheter approximately 2 to 3 inches
into the tube. If the patient begins to cough, the catheter is through the tube and into the trachea, and the depth of insertion
is correct. Do not use suction while inserting the catheter, and never force the catheter.
Cover the suction port (hole) and suction for 3 to 5 seconds, while slowly removing the catheter. Never suction for longer
than 10 seconds.
Always monitor the patient’s heart rate and color during this procedure. Stop suctioning immediately if the heart rate begins
to drop or the patient becomes blue.
If the obstruction is removed, and the patient can breathe on his/her own, do not suction further. If additional suctioning is
needed, apply oxygen (by blow-by or direct ventilation) and repeat steps
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Accidental Decanulation
• Early accidental
decanulation.
• Nasal speculum
• Obturator
• Risk of false
tract/fistula
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Leaks
A low-pressure, high volume
cuff is preferred to avoid
unnecessary injury to the
tracheal mucosa such as
tracheal malacia.
1. Check cuff pressure first.
2. Consider changing to a
longer tracheostomy tube.
3. Monitor cuff pressure on a
regular basis.
Shiley® Tube
Size
Leak Test
Volume
10
20cc
8
17cc
6
14cc
4
11cc
Bleeding
• Local bleeding
– Granulation tissue
– Superficial bleeding
from mucosa
– Small vessels
• Controlled with
– Pressure dressing
– Gelfoam
– Chemical
cauterization
Bleeding
But for anything more than oozing. Must rule out
tracheo-innominate artery fistula (TIAF).
Caused include;
•Low tracheostomy
•High innominate
artery
•Cuff overinflation
•Infection
Bleeding
• TIAF may cause
massive hemorrhage in
0.7% of tracheotomies.
• 2/3 occur in first 3
weeks after
tracheostomy
• Long-term intubation
and ventilation.
• Cuffed or uncuffed
tube.
Changing Tracheostomy
• In the absence of aspiration, tracheostomy tube cuffs should be
deflated when the patient no longer requires mechanical ventilation.
• A patient initial tracheostomy tube should normally be replaced within
10-14 days.
• The Panel agreed an experienced physician should ideally be present
for the first tube change, although there are was recognition that in
some facilities, this may not be feasible and thus performed by an
experienced advanced practice provider (APP) with immediate
physician backup available.
• In an emergency, a dislodged, mature tracheostomy tube should be
replaced with the same size or a size smaller tracheostomy tube. If
those are not available for could not be inserted, then an appropriately
sized endotracheal tube should be placed through the wound into the
trachea. In a patient in whom a tube could not be replaced, resulting in
hypoxia or concern for eventual loss of airway, they should undergo oral
tracheal intubation or immediate surgical revision tracheostomy.
Decannulation
When the adult patient is in the hospital and;
1. Does not require mechanical ventilation
2. Indication for tracheotomy has resolved
3. Patient tolerates breathing through the tracheotomy tube
with the cuff deflated.
4. Breathing with a cuffless #6 Shiley tube is checked
(smaller patients, a cuffless #4 Shiley tube is placed)
5. Patient tolerates capped tracheostomy with a red button.
6. If the patient is stable (normal oxygen and CO2) for 24 –
48 hours with the trach plugged, the tube will be removed
by a qualified physician or mid-level provider, and the
stoma will be allowed to close.
Downsizing, capping and decannulation
Decannulation
Downsizing, capping and decannulation
Decannulation
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.
Decannulation
Assess the patient for associated
anomalies of the nervous,
respiratory, cardiovascular and
gastro-intestinal systems.
Re-examine the airway for
associated problems: nasal
obstruction, adenoid
hypertrophy, tonsil hypertrophy,
macroglossia, glossoptosis,
micrognathia, lingual tonsil
hypertrophy, laryngomalacia,
glottic web, sub-glottic stenosis,
tracheal stenosis or granulation
Mercado 2011 ©
Late Complications
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Bleeding
Tracheomalacia
Stenosis
Tracheoesophageal
fistula
• Tracheocutaneous
fistula
• Granulation
• Leaks
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Tracheotomy- Conclusion
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2.
3.
4.
Identify source of leaking and
bleeding.
If unable to safely change
tracheostomy at bedside
consider revision
tracheostomy in OR.
Care of the tracheostomy
tube and the wound require
planning and communication.
Do only as much as you have
been trained to, feel
comfortable doing and is
within your scope of practice.
Mercado 2011 ©
Practice mannequins
available to practice
tracheostomy care
technique.
Clinical Consensus Statement
• Tracheostomy tube should be changed using a clean technique. A
sterile technique is not necessary and does not lead to a reduction in
impaction.
• Plastic tracheostomy tube should be used among pediatric and adult
patients for initial tube placement.
• Tracheostomy tube ties it should be used unless the patient recently
underwent local or free flap reconstructive surgery or other major neck
surgery.
• No patient should be discharged with tracheostomy tube sutured in
place. Any suture securing a tracheostomy should be removed during
first tube change.
• Stoma and tracheostomy tube should be suctioned when there is
evidence of visual or audible secretions in the airway, suspected airway
obstruction, and whether tube is changed or deflated.
Links
Aaron’s Tracheostomy Page
http://www.tracheostomy.com/
Station 4
PTA
Station 2
Control
A/P
Epistaxis
SMR *
Removal FB
Chair
Station 1
Control
A/P
Epistaxis
Station 5
FNA
Removal FB
Station 3
Trach
Care
Station 6
FNA
*suction