When you start in any job you feel like you are "in at the deep end". ENT is no exception, not only is the anatomy unfamiliar, but so are the conditions encountered and the instruments used to examine and treat patients.
The aim of this tutorial is to introduce you to some of the equipment you are likely to see in your out patient clinic and treatment room. This is not exhaustive and some equipment in your department may differ, but the majority of instrument types are covered with a brief word about each. Hopefully reading this might give you a head start for that first night on call!
This is an example of a typical ENT clinic trolley. Along with the basic instruments you will find swabs, suction devices, heating devices and various light sources.
Here is an otoscope. This is primarily used to examine the ear, but can in fact be used for much of the routine ENT examination. The example shown is designed for use with a disposable speculum. The instrument contains its own light source and magnification to give a view of the tympanic membrane.
When examining the ear, the pinna should be pulled up and backwards to help straighted the ear canal. The correct size of speculum will then allow examination of the ear canal and tympanic membrane.
This instrument can be used as a light source for examining the oral cavity and also for nasal examination.
Above is a selection aural speculums. The far right plastic variety is designed for use with the otoscope. The other two are metallic and are used in conjunction with an operating microscope for ear examination. A speculum helps hold the ear canal open for examination. This is essential for much of the work done with a microscope, and a variety of sizes and shapes are available. A close up with name and size numbering is shown below. This is a "Rosen" size 4.
This unusual instrument is called nasal thuddicums. These are used to hold the nostril open and allow examination of the nasal cavity. A light source (usually a head mirror) must be used at the same time.
Holding this instrument is uncomfortable at first, but with practice becomes second nature. First hold your dominant hand flat, palm facing up, and place the instrument over the distal interphalangeal joint of your index finger with the blades pointing towards you. The next part can be hard to imagine, and is best done with an instrument if possible. You now pronate your forearm 90 degrees. The instrument should still be hanging from your index finger. Now pass you middle finger around one leg of the instrument and your ring finger around the other. This allows you to compress the legs between middle and ring fingers. Now curl your index finger towards you and the blades face away. These are inserted into a nostril under compression then by relaxing your middle and ring fingers the aperture is held open to allow examination. I would suggest a few dry runs before using a live patient!
Above are a pair of Tilley's forceps. These are commonly called dressing or packing forceps, and are generally used in the nose. You are likely to use them to pack noses and remove foreign bodies. Other types of forceps are available. Crocodile forceps are hinged near the tip. This allows you to grab smaller items. They are used to place grommets in the ear in theatre, and can be useful for some ear work in the clinic also. Other biopsy forceps with sharp edges are available but are more likely to be encountered in theatre.
There are two basic kinds of tongue depressor. The wooden ones are disposable and also the most common. Metallic instruments can be used is more force is required. There are different sizes of metallic tongue depressor, and small ones can be used in children or infants. In fact it is sometimes easier to both find and use a teaspoon for kids.
This is a laryngeal mirror. It is used to see over the back of the tongue and into the larynx. This examination is difficult to learn and you should try to get a more experienced colleague to teach you.
The mirror should be heated to stop condensation forming on its surface. The patient is instructed to hold their mouth open and stick out their tongue. You should pull the tongue forwards with a dry swab then insert the mirror towards the soft palate. With a well-angled light and plenty of practice you should be able to see over the tongue. Patients who gag excessively may prefer to have a local anaesthetic spray before the examination. Similar mirrors can be used to examine the post nasal space.
Above is a local anaestietic spray
An increasingly common way to examine the larynx is with a flexible nasendoscope as shown above. This is passed along the floor of the nose into the nasopharynx and allows examination of the nasal cavity, nasopharynx, oropharynx hypopharynx and larynx. Again you should ask someone to show you how to use this expensive and fragile piece of equipment. A light source is required to operate the endoscope.
This is a different kind of endoscope, a rigid nasendoscope. As the name suggests this is used to examine the nasal cavity and nasopharynx. It must be connected to a light source and gives a magnified view. Preparing the nose with a decongestant spray will allow a better view and also helps control bleeding, especially helpful in managing epistaxis.
Each rigid scope has a different viewing angle. Most are either 0 degree (looking straight ahead) or 30 degree scopes but occasionally you see a 70 degree scope. Straight viewing scopes are easier to use, but angled scopes can be more versatile allowing the user to see into different places. The 70 degree scope is difficult to use and I would advise starting with a straight scope before moving on to the angled variety.
Here is an operating microscope. There are many different kinds and you will find them in clinics, treatment rooms and operating theatres. They tend to be used for examining the ear. Used in conjunction with an aural speculum they allow different levels of magnification and also give you a free hand to use a suction device for clearing the ear canal. There are various dials and adjustments to be made. Finding the on/off switch can be hard in itself!
First check that both eyepieces are correctly focussed. If you don't know your own settings for the scope you can look down one side and get the whole scope in focus then look down the other side (with the other eye) and focus the eyepiece separately.
Next check that distance between the pieces is equal to your inter-pupillary distance. You probably don't know this yet so you just have to try and see. Now check that the light source is connected and working. Choose the level of magnification (low magnification is easier to use) and move the microscope to focus it. There tends to be a dial for fine adjustments to focus. All microscopes are slightly different and it is important for you to get used to the one you will be using. Instruction manuals are generally available somewhere and with practice your skills will improve.
Below is an example of a suction catheter. This one is disposable, but there are also metallic "Zollinger" suction catheters available. These devices sometimes have a hole in the side. This provides finger-control which can vary the amount of suction applied accurately. You will find suction invaluable for treating ear conditions and in management of epistaxis.
You should become familiar with the different suction catheters available. You department is likely to have the ones shown as well as Yanker suckers and Tracheal suction catheters. You may be familiar with Yanker suckers from theatre, they are wider than the one shown above, some have finger control and can be used to remove blood clots or thick oral secretions.
Tracheal suction catheters are long, flexible and fine bore. They always have finger control and are normally used for suctioning down tracheostomies. They come in a sterile packet. When you use one you should try to keep the catheter tip sterile and some departments like you to wear a sterile glove. The catheter is inserted with the finger control uncovered so you only apply suction on removal of the catheter. These are also available in a variety of sizes.
Finally you will come across tuning forks. There are a range of different forks, all of which have a different pitch. The two tests you will be expected to understand are Webers and Rhinnie's test. Explanations of these can be found elsewhere, but remember that you should pick a fork with a pitch over 128HZ as if you don't the patient may detect the vibration of the fork and not just the sound.
As you work in ENT you will come across hooks, hoops, probes and other bits of kit not mentioned here. With practice you will be soon become familiar with the use of instruments in clinics, theatre and on the ward.
