9.4 ENT, Ophthalmic, Maxillofacial, and Reconstructive Procedures

9.4 ENT, Ophthalmic, Maxillofacial, and Reconstructive Procedures

Head, neck, ophthalmic, maxillofacial, and reconstructive specialties require intricate knowledge of micro-instrumentation, delicate handling of specialized tissues, microsurgical equipment operation, and stringent airway safety protocols.

For the Tech in Surgery - Certified (NCCT TS-C) exam, candidates must master specialized instrumentation (operating microscopes, microdebriders, dermatomes, nerve stimulators, phacoemulsification units), intraocular pharmacology, maxillomandibular fixation airway protocols, skin graft classification, and flap reconstruction dynamics.

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1. Otolaryngology (ENT / Head & Neck Surgery)

Otolaryngology encompasses operative management of the ear (otology), nose and sinuses (rhinology), and oral cavity, pharynx, and larynx (laryngology / head & neck).

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|                        ENT PROCEDURAL CATEGORIES                            |
|                                                                             |
|   [OTOLOGY (EAR)]       [RHINOLOGY (SINUSES)]     [LARYNGOLOGY & NECK]      |
|   - Myringotomy & Tubes - FESS (Sinus Endoscopy)  - Tonsillectomy & Adenoid |
|   - Tympanoplasty       - Septoplasty / Rhino     - Tracheostomy (Airway)   |
|   - Mastoidectomy       - Epistaxis Ligation      - Radical Neck Dissection |
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1. Otology: Myringotomy and Tympanoplasty

• Myringotomy & Pressure Equalizing (PE) Tube Insertion: Indicated for chronic otitis media with effusion. The operating microscope is positioned -> Ear speculum placed in external auditory canal -> Cerumen cleared with Buck curette -> Anterosuperior or anteroinferior radial incision made in the tympanic membrane using a myringotomy knife -> Middle ear fluid aspirated using Baron suction (#3 or #5 French) -> PE tube (Armstrong, Bobbin, or Donaldson tube) grasped with alligator forceps and seated across the tympanic incision.
• Tympanoplasty: Reconstruction of a perforated tympanic membrane and ossicular chain. Autologous temporalis fascia graft is harvested and pressed in a fascia press. Middle ear ossicles (malleus, incus, stapes) are inspected and reconstructed using Partial Ossicular Replacement Prostheses (PORP) or Total Ossicular Replacement Prostheses (TORP).
• Mastoidectomy: High-speed bone drill with continuous sterile saline irrigation used to resect diseased mastoid air cells (cholesteatoma). Continuous irrigation is essential to prevent thermal osteonecrosis and thermal injury to the adjacent facial nerve (Cranial Nerve VII). Intraoperative facial nerve monitoring is standard.

2. Rhinology: Functional Endoscopic Sinus Surgery (FESS)

FESS restores physiological mucociliary clearance of the paranasal sinuses (maxillary, anterior/posterior ethmoid, frontal, and sphenoid sinuses).

• Equipment: Rigid 4 mm endoscopes (0-degree, 30-degree, 70-degree), high-definition camera console, CT-guided electromagnetic optical navigation system, and motorized microdebrider (shaver) with continuous suction/irrigation.
• Topical Vasoconstrictors: 4% Cocaine solution or oxymetazoline (Afrin) applied via neuro-cottonoids / pledgets to shrink nasal mucosa and achieve hemostasis.
• Operative Sequence: Uncinectomy (removal of uncinate process with sickle knife) -> Maxillary antrostomy (widening of natural ostium) -> Anterior and posterior ethmoidectomy (using Blakesley, Takahashi, and microdebrider) -> Sphenoidotomy / Frontal sinusotomy -> Hemostatic nasal packing.

[!WARNING] Critical Hazards during FESS:

1. Orbital Injury: Penetration through the paper-thin medial orbital wall (lamina papyracea) causes intraorbital hemorrhage, rapid proptosis, elevated intraocular pressure, and optic nerve ischemia. (CST must monitor patient's eye for proptosis if un-draped).
2. Intracranial Entry: Penetration through the cribriform plate of the ethmoid bone results in cerebrospinal fluid (CSF) rhinorrhea, meningitis, or direct brain injury.

3. Laryngology & Head/Neck: Tracheostomy and Tonsillectomy

• Tracheostomy: Creation of an anterior tracheal stoma to secure a definitive airway in prolonged mechanical ventilation or upper airway obstruction.
  • Sequence: Horizontal collar or vertical midline incision between cricoid cartilage and suprasternal notch -> Strap muscles (sternohyoid, sternothyroid) retracted laterally with Army-Navy or Senn retractors -> Thyroid isthmus divided between hemostats and suture-ligated -> Cricoid hook elevates cricoid cartilage superiorly -> Trachea entered between 2nd and 3rd tracheal rings with #15 blade -> Trousseau tracheal dilator spreads tracheal incision -> Tracheostomy tube (e.g., Shiley, Jackson) with inner obturator inserted smoothly -> Obturator removed immediately -> Inner cannula locked into place -> Pilot balloon inflated -> Anesthesia connects circuit and confirms bilateral breath sounds -> Trach tube secured with sutures and tracheostomy twill tape around neck.
• Tonsillectomy & Adenoidectomy (T&A): Mouth opened with Crowe-Davis or Jennings mouth gag (ensure patient's tongue and lips are not pinched/ischemic). Tonsil grasped with tonsil ballenger/alligator clamp, retracted medially, and dissected using suction coagulator, Fisher tonsil knife, cold snare, or coblation wand. Bleeding controlled with suction cautery and tonsil sponges with strings.

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2. Ophthalmic Surgery and Intraocular Pharmacology

Ophthalmic surgery requires extreme precision, microscopic dexterity, absolute immobilization of the globe, and strict lint-free protocols.

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|                          OCULAR GLOBE ARCHITECTURE                          |
|                                                                             |
|                [CORNEA] ===> [ANTERIOR CHAMBER (Aqueous)]                   |
|                    |                    |                                   |
|                 (Pupil) <========== [IRIS]                                  |
|                    |                    |                                   |
|             [CRYSTALLINE LENS] <=== [POSTERIOR CHAMBER]                     |
|                    |                                                        |
|             [VITREOUS BODY] (Posterior Cavity / Gel)                        |
|                    |                                                        |
|                 [RETINA] ===> [CHOROID] ===> [SCLERA]                       |
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1. Cataract Extraction via Phacoemulsification

Cataract is an opacification of the natural crystalline lens causing progressive vision loss.

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|                        PHACOEMULSIFICATION SEQUENCE                         |
|                                                                             |
|   1. CORNEAL INCISION & VISCOELASTIC INJECTION                              |
|      - Clear corneal incision made with diamond or steel keratome knife.    |
|      - Viscoelastic agent (Healon / Provisc) injected to maintain chamber.  |
|                                                                             |
|   2. CONTINUOUS CURVILINEAR CAPSULORHEXIS (CCC)                             |
|      - Cystotome needle or Utrata capsulorhexis forceps tears circular      |
|        opening in anterior lens capsule.                                    |
|                                                                             |
|   3. HYDRODISSECTION                                                        |
|      - Balanced Salt Solution (BSS) injected via flat cannula to separate   |
|        lens cortex from posterior capsule.                                  |
|                                                                             |
|   4. ULTRASONIC PHACOEMULSIFICATION                                         |
|      - Phaco handpiece emulsifies and aspirates lens nucleus with ultrasound|
|      - Automated Irrigation/Aspiration (I/A) handpiece clears cortical remnants
|                                                                             |
|   5. INTRAOCULAR LENS (IOL) IMPLANTATION & VISCOELASTIC CLEARING            |
|      - Capsular bag inflated with viscoelastic.                             |
|      - Foldable acrylic IOL loaded into injector cartridge and deployed.    |
|      - Viscoelastic COMPLETELY ASPIRATED to prevent post-op glaucoma.       |
|      - Incision sealed with BSS hydration (stromal hydration).             |
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Ophthalmic Pharmacology Matrix

[!IMPORTANT] Ophthalmic Lint-Free Safety Mandate: Standard woven cotton gauze (4x4s, raytecs) is strictly prohibited in intraocular ophthalmic surgery because loose cotton lint shedding into the eye causes severe foreign-body granulomatous uveitis and endophthalmitis. Surgical technologists must use only specialized, sterile, lint-free compressed cellulose eye spears (Weck-Cel sponges).

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3. Oral and Maxillofacial Surgery (OMFS) & Facial Trauma

Oral and maxillofacial surgery manages complex facial fractures, orthognathic deformities, and reconstructive jaw procedures.

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|                        LE FORT FRACTURE CLASSIFICATIONS                     |
|                                                                             |
|   [LE FORT I: Transverse / Floating Palate]                                 |
|   - Horizontal fracture line traversing maxilla above alveolar ridge,       |
|     nasal septum, and pterygoid plates.                                     |
|                                                                             |
|   [LE FORT II: Pyramidal Fracture]                                          |
|   - Triangular fracture through nasal bones, frontal process of maxilla,    |
|     lacrimal bones, orbital floor, and infraorbital rim.                    |
|                                                                             |
|   [LE FORT III: Craniofacial Disjunction]                                   |
|   - Complete separation of facial bones from skull base; fracture line      |
|     traverses nasofrontal suture, orbital walls, and zygomatic arches.      |
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Maxillomandibular Fixation (MMF / Arch Bars)

MMF aligns the maxillary and mandibular dental arches into correct anatomical occlusion prior to rigid plate fixation.

• Technique: Erich arch bars are custom-contoured to the upper and lower dental arches and secured to individual teeth using pre-stretched 24-gauge or 26-gauge stainless steel wire ligatures twisted with a wire twister. Intermaxillary wire loops or heavy elastic bands are then applied to lock the jaws into occlusion.

[!CAUTION] CRITICAL AIRWAY SAFETY PROTOCOL FOR MMF: When a patient's jaws are wired shut with arch bars, postoperative vomiting, bleeding, or laryngospasm can cause catastrophic airway obstruction and fatal pulmonary aspiration. Wire cutters (or scissors for elastics) MUST accompany the patient to PACU / ICU and remain taped to the head of the patient's bed or tracheostomy tray at all times to allow immediate cutting of the wires during an airway emergency.

Rigid Internal Fixation (RIF) of Facial Bones

Facial skeleton fractures (mandible, maxilla, zygoma, orbital rim) are fixated with titanium mini-plates (1.0 mm to 2.0 mm) and monocortical or bicortical self-tapping titanium screws. Technologists must ensure drill guides with built-in depth stops are used to avoid injuring tooth roots and the inferior alveolar nerve within the mandibular canal.

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4. Plastic, Reconstructive, and Aesthetic Surgery

Plastic surgery encompasses tissue transfer, burn reconstruction, aesthetic refinement, and microvascular reconstruction.

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|                     SKIN GRAFT CLASSIFICATION MATRIX                        |
|                                                                             |
|   [SPLIT-THICKNESS SKIN GRAFT (STSG)]     [FULL-THICKNESS SKIN GRAFT (FTSG)]|
|   - Epidermis + Variable Dermis (0.010"-  - Epidermis + Entire Dermis       |
|     0.018" thickness).                    - Harvested with scalpel (#15).   |
|   - Harvested with motorized dermatome    - Subcutaneous fat trimmed clean  |
|     (Zimmer / Padgett / Brown).             (defatted) with iris scissors.  |
|   - Lubricated with mineral oil.          - Donor site closed primarily     |
|   - Expanded via mesh graft expander        with sutures (linear scar).     |
|     (1.5:1, 2:1, 3:1 ratio).              - Superior cosmetic & texture     |
|   - Covers extensive burn surfaces;         match for face, hands, eyelids. |
|     donor site re-epithelializes.                                           |
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1. Skin Grafting Protocols

• STSG Harvesting Sequence: Donor site (thigh, buttocks) prepared and prepped -> Sterile mineral oil applied to donor skin and dermatome blade to reduce friction -> Oscillating powered dermatome (calibrated to 0.012–0.015 inch thickness) held at a 45-degree angle and pressed firmly against skin -> Harvested graft placed in saline -> Graft fed through a mesh graft expander (derma-carrier) to create slit perforations (allows blood/serous fluid escape and expands graft surface area up to 3x) -> Graft stapled or sutured to recipient bed with bolster dressing (stent dressing) applying uniform downward pressure -> Donor site dressed with non-adherent hemostatic dressing (Xeroform, Aquacel Ag, or Opsite).
• FTSG Sequence: Donor site (groin crease, supraclavicular fossa, pre/post-auricular) templated with foil pattern -> Excised sharply with scalpel -> Graft placed dermal side up on wet board and subcutaneous fat aggressively trimmed off with curved tenotomy/iris scissors (defatting) until pale white dermis is exposed (essential for vascular imbibition) -> Recipient bed inset with 4-0/5-0 nylon sutures and bolster tie-over dressing -> Donor site closed primarily in layers.

2. Flap Reconstruction Dynamics

Unlike skin grafts (which lack an intrinsic blood supply and rely on vascular ingrowth from the host bed), flaps retain their own intrinsic vascular perfusion.

• Pedicle Flaps: Tissue transposed while maintaining an intact vascular pedicle (e.g., Latissimus dorsi myocutaneous flap rotated onto anterior chest wall).
• Free Flaps (Microvascular Free Tissue Transfer): Tissue completely detached from donor anatomical bed and transplanted to recipient site, requiring microvascular anastomoses of the feeding artery and draining vein under an operative microscope.
  • Examples: DIEP Flap (Deep Inferior Epigastric Perforator - skin and fat from lower abdomen for autologous breast reconstruction, sparing rectus muscle); TRAM Flap (Transverse Rectus Abdominis Myocutaneous flap); Fibula Free Flap (vascularized fibular bone graft for mandibular reconstruction).
  • Micro-Sutures: 8-0, 9-0, and 10-0 monofilament nylon on ultrafine BV/CC needles; antispasmodics (Papaverine or Lidocaine 2%) irrigated over micro-vessels to prevent arterial vasospasm.