ent final and dhingra tables

15. Acute Tonsilitis

23. Conductive Hearing Loss Sensorineural Hearing Loss
1. Negative Rinne test, i.e. BC > AC.
2. Weber lateralised to poorer ear.
3. Normal absolute bone conduction.
4. Low frequencies affected more.
5. Audiometry shows bone conduction better than air conduction with air-bone
gap. Greater the air-bone gap, more is the conductive loss.
6. Loss is not more than 60 dB.
7. Speech discrimination is good.
1. A positive Rinne test, i.e. air AC > BC.
2. Weber lateralised to better ear.
3. Bone conduction reduced on Schwabach and absolute bone conduction
tests.
4. More often involving high frequencies.
5. No gap between air and bone conduction curve on audiometry (Fig. 5.6).
6. Loss may exceed 60 dB.
7. Speech discrimination is poor.
8. There is difficulty in hearing in the presence of noise.

68. Indications in Children
• Local
• Systemic
• Local Could be:
– Laryngeal e.g.
• Congenital subglottic stenoiss
• Laryngeal web
• Haemangioma of larynx sub-glottis
• Acute epiglottitis
• Acute LTB
• Laryngomalacia
• Sub-glottic oedema
• FB Larynx

69. – Above larynx e.g
• Micrognathia
• Pierre – Robin syndrome
• Harmatoma and teratoma of nasopharynx & pharynx
• Meningo – encephalocoele
– Below larynx
• Tracheomalacia
• Tracheal hemangiomas
• Cystic hygroma compressing trachea
– Systemic e.g
• Arnold Chiari malformations
• VSD, ASD, tetralogy of fallot
• Congenital myopathies
• Congenital multiple neurofibromatosis
• Anoxic encephelopathy
• Bulbar poliomyelitis

70. Types of Tracheostomies
• Depending on type of urgency:
– Emergency tracheostomy – UAO necessitating urgent
intervention where intubation or coniotomy is not
helpful or possible
– Elective tracheostomy (tranquil, orderly, or routine
tracheostomy). This is planned, unhurried procedure.
Further classified into
• Temporary; only for some time to overcome crisis
• Permanent; done forever; tracheal stump is brought to the
surface and stitched to the skin e.g in:
– Bil Abductor paralysis
– Laryngectomy
– Laryngeal stenosis

71. • Depending on anatomic siting:
– High tracheostomy: done above level of thyroid
isthmus. Main indication is ca larynx prior to
laryngectomy
– Mid tracheostomy: preferred one. Done through 2nd
and 3rd tracheal rings. Thyroid isthmus is reflected
upwards or dissected and divided
– Low tracheostomy: below level of isthmus: tracheal
rings 4/5. Trachea is deep at this level and close to
large vessels, and close to carina of trachea
• Main indication: juvenile laryngeal papillomatosis to avoid
implantation. Use short T-tube to avoid impinging on carina.
Best done immediately below the isthmus.

72. • Depending on Rx need
– Therapeutic tracheostomy: done to relieve resp.
obstruction
– Prophylactic tracheostomy: done to guard against
anticipated resp. obstruction or aspiration in
ostensive neck/oral surgeries

73. Steps in Operation
• Incisions
– Vertical: usually 4 cm long in midline extends from
lower border of cricoid. Good in Caucasians, Asians,
in emergency
– Transverse: horizontal incision 5 cm long, approx. 2
finger breaths above sternal notch. Good for Africans
to avoid ↑ risk of kelloid formation, and elective cases
– Structures you go through
• Skin
• Subcutaneous tissue + fat, ant. communicating vein
• Deep cervical fascia divided, retracted (laterally)
• Strap muscles (stenothyroid, sterohyoid) are split in midline
& retracted laterally
• Pre-tracheal layer is divided – exposes isthmus of thyroid

74. • Isthmus is either
– Retracted upwards using hook retractor
– Divided and retracted laterally; take care of inferior
thyroid veins which are either:
• Retracted
• Ligated
– Pretracheal fascia divided & retracted; this bares the
tracheal rings
– Stabilize the cricoid cartilage using tracheal retractor
(or cricoid hook)
– Inject 4% lignocaine into trachea to anesthetize the
tracheal mucosa and confirm you are in the airway

75. Tracheal Opening
• Children: cut trachea vertically or horizontally; no cartilage
removed
• Adults
– Open window between lower part of 2nd tracheal ring and upper
part of 4th ring
– Cut made in midline, avoid injury to recurrent laryngeal nerve
– Or cut tracheal flap either superiority or inferiority.
• Insert T-tube using tracheal dilators (cuff inflated)
– Secure T-tube; suturing either flange on skin of neck and using
straps after flexing the neck
– Suture skin of wound not very tightly to avoid surgical
emphysema occurring
– Gauze dressing is placed between the skin and flange of tube
around the stoma

76. Post Op Care II
• Aseptic precautions during suction
• Constant supervision for
– Bleeding
– Tube displacement
– Tube blockage
– Maintenance of tube patency
– Communicate with patient; call bell

77. • Prevention of Crusting & trachietis
– Proper humidication use of humidifier, steam tent
or boiling water kept in the room
– Drops of normal saline or hypotonic saline into
tube every 2 – 3 hours to loosen crusts
– Give a mucolytic agent to liquefy tenacious
secretions

78. • Care of tube
– If double barrel tube, inner canula be removed and
cleaned PRN for 1st 3 days
– Outer tube, unless blocked or displaced should not be
removed for 3 – 4 days till a track is formed to enable easy
replacement of tube
– Once track is formed, tube be removed and cleaned once
every week
– If tube is cuffed, deflate it periodically every hour for 5 –
10 minutes to prevent pressure necrosis of trachea
– Nurse patient with extra tube by bedside; same size or one
size less then the one in situ
– Dress the tracheostomy site to prevent infection and
maceration of skin around the stoma.
– Tracheobronchial toileting is done regularly using suction
tube with Y-connector. Always suck outwards(avoids
suction injury to mucosa).

79. Complications of Tracheostomy
• Intra-operative
– Haemorhage
– Apnea in patients with prolonged UAO (hypoxic drive lost)
Rx: administer 5% CO2 or give assisted ventilation
– Pneumothorax ; injury to apical pleura
– Injury to recurrent laryngeal nerves
– Blood aspiration
– Oesophageal injury during making of opening into trachea
– TOF
– Air embolism
– Lung collapse

80. • Intermediate
– Reactionary hemorrhage
– Tube obstruction/displacement
– Subcutaneous emphysema (surgical)
– Tracheitis, lung infections
– LTB
– Granulation tissue
– Dysphagia
– Local wound infection

81. • Late
– Difficult decannulation (tube addiction – children)
– Hemorrhage; 2⁰ to erosion of innominate artery –
could be fatal
– Tracheomalacia
– Subglottic stenosis; perichondritis of cricoid cartilage
– TOF
– Incoordination of laryngeal opening reflex
– Persistent tracheocutaneous fistula
– Scar formation
– Granulation tissue through stoma
– Corrosion of tracheostomy tube – aspiration of
fragment (FB)

82. Tracheostomy in Infants/Children:
Points to note
• Trachea
– Soft & compressible
– May be mistakenly displaced laterally
– Solution: ETT into trachea or bronchoscope prior to
tracheostomy
• Tracheostomy in children is usually done under
GA
• During positioning, don’t hyperextend the neck
as this pulls chest structures into the neck. Injury
to pleura, innominate vessels & thymus

83. • Before incising the trachea, silk sutures are placed in trachea on
either side of midline
• Trachea lumen is small; don’t insert knife too deep lest you injure
the posterior tracheal wall or oesophagus causing TOF
• Trachea is incised longitudinally without removal of circular piece of
tracheal well – trachea still growing
• Avoid infolding of anterior tracheal wall when inserting tube
• Proper tube selection very important i.e.
– Proper diameter
– Length
– Curvature
A long one will impinge on carina or Rt bronchus
– Use of soft silastic or portex tubes. Metallic tubes cause more trauma
• Take CXR post op of neck & chest to ascertain position of T-tube

84. Decannulation
• Process of weaning the patient off the tracheostomy tube
• R/o Proximal obstruction by taking X-ray neck AP, lat CxR to
visualize tracheal lumen below & above the tracheostomy
• In children, arterial blood gases may be required
• Direct ± indirect laryngoscopy and occasionally tracheo-
bronchoscopy to R/o proximal obstruction
• Insert a tube smaller in size than the one in situ and former
be fenestrated
• Spighort (cork) the T-tube starting with few minutes then and
all it is for a day. If patient tolerates corking for 48 hrs or
more, then remove tube, wound strapped or sutured.

85. • Principles of decannulation in children
– Decannulation in operation theatre where facilities
are at hand
– Equipment for re-intubation should be at the ready
• Good headlight laryngoscope
• Proper size ETT
• Tracheostomy tray
– After decannulation, observe child for several hours
for
• Resp. distress
• Tachycardia
• colour

86. • Factors leading to difficult decannulation
– Persistence of condition of which tracheostomy was
done
– Grannulations around stoma or below it where tip of
tracheostomy tube was hanging
– Tracheal oedema
– Subglottic stenosis
– Incurving of tracheal wall at the site of tracheostomy
– Psychological dependence in children
– Inability to tolerate upper airway resistance on
decannulation
– Tracheomalacia
– Incoordination of laryngeal opening reflex
– Impaired development of larynx due to long standing
tracheostomy

89. Laryngeal paralysis

103. RX streptomycin 1g/d
Tetracyclin 2g/d

132. A
A
A
C
C
D
M