Friday, September 25, 2009

History of Mastoidectomy

Introduction: “One who ignores history would do so at his peril, to be condemned to repeat the same mistakes”. A study of history of mastoid surgery and its instrumentation is important in a sense that they are the tombstones to our success today. Eighteenth century is characterized by advancement in instrument designs and sterilization techniques. Heat resistant metals were used to manufacture surgical instruments as they had to withstand extremely high sterilization temperatures. Our forefathers of 18th century were great innovators and to their credit even now majority of mastoid instruments in use were conceived and designed by them.

Mastoidectomy during different eras:

The art and craft of Mastoidectomy has evolved during the past 200 years. The process of this evolution can be studied under three different eras i.e.:

1. Era of trepan (18th century)

2. Era of chisel & gouge (Early 19th century)

3. Era of electrical drill (20th century)

Era of Trepan:

Trephination was performed to let out pus. This was extensively practiced during the 18th century to let out pus from skull bones. The first successful trephination of mastoid cavity was performed by Ambroise Pare during 16th century. Younger during 17th century devised a hand Trepan which he used extensively to perform this procedure. A hand held trepan was commonly used during this period. The cutting head of trepan used could be circular (to cut a circular piece of bone), exfoliative head (to shed the superficial layer of bone), and perforative head (used to make a hole in the bone). In 1736 Jean Louis Petit performed the first mastoid opening for a patient with mastoid abscess. Pus His main aim was to create a hole through which pus from the mastoid cavity can drain. While using a Trepan it should be dipped in cold water often to reduce heat generated during the procedure.

In 1776 Jasser used a trocar to open up the mastoid cavity. He used the nozzle of a syringe to aspirate the contents from the mastoid cavity. This surgical procedure hence was aptly named as “Jasser procedure”. The term “trocar” has its origin in French language. “Toris – quarts” is a French word to describe an instrument with three cutting sides used to make a hole. American otologist Fredreik White described this era of mastoid surgery as an experimental one. This experimental era proved that the concept of opening up the mastoid cavity and draining the secretions is a possibility. The instrumentation was of course woefully inadequate. The first catalogue of surgical instruments published in 1860’s mentioned the various surgical and dental instruments in use. Mastoid instrumentation of course did not find a place in that catalogue.

Chisel & Gouge period: This period was characterized by the introduction of general anesthesia which facilitated a surgeon to operate leisurely on a patient. It was Amedee Forget a French surgeon who used a mallet and gouge to open the mastoid cavity and drain the accumulated pus. He performed this surgery during 1860.

Modern mastoid surgery was pioneered by the German otologist Scwartze during 1873. He and his assistant Adolf Eysell abandoned the use of Trepan in favour of chisel and gouge. He popularized Chisel and gouge as he was convinced that it was the safest way to open up the mastoid antrum. His assistant had drawn up detailed illustrations of the various types of chisel and gouges used in this procedure. Buck introduced the small curette that could be used to widen the aditus. He also advocated continuous chiseling of the hard mastoid cortex till the soft bone is reached which could be curetted out rather easily using curettes of varying sizes.

Initially Volkmann sharp edged spoons were used as curette. Samuel Kopetzky, American otologist advised that one should become dexterous and elegant with the use of a set of instruments. Newer instruments (design wise) should be introduced only when they have distinct advantages over the tried out older ones. This observation holds good even today.

Electrically driven drill period: “Modern era Mastoidectomy”

Electrically driven drills were used to manage dental caries even way back in 1882. It was William McEwen who drew the attention of the world to this unique device. He believed that the safest instrument that can be used to drill the mastoid antrum is the rotating burr. It had better control and uniform rotator cutting ability. The size of the burr bits can vary according to the area of surgery. It was Julius Lempert in 1922 who really popularized the use of electrically driven drill in ear surgeries. William House introduced the suction irrigation system and retractors in mastoid surgery. He observed that while performing ear surgeries a surgeon needs to keep both hands useful.

Holmgren introduced the operating microscope which really made Mastoidectomy totally a safe procedure.

Tuesday, September 08, 2009

An interesting videolaryngoscopy

You will be seeing here an interesting videolaryngoscopy.  This 75 years old female patient came with complaints of breathlessness - 1 year.  On examination she was found to be in mild stridor.

Given below is the videolaryngoscopy movie.

Saturday, September 05, 2009

Role of microdebriders in nasal endoscopic sinus surgery

History: Microdebrider surgical technique was first introduced by Urban in 1968 for removing large acoustic neuromas. This instrument became a fancied tool for orthopedic surgeons who specialised in joint surgeries. Later on plastic surgeons started using this technique for performing liposuction procedures. Otolaryngologists did not lag behind in adapting this equipment for nasal surgeries.

Components of microdebrider:
A debrider contains three components.

1. The console which helps in controlling the speed of rotation/direction of rotation. These parameters can easily be changed with the help of a attached foot pedal.
2. The blade: This is a tubular metal structure with serrated edge / smooth edge. The cutting edge is present only on one side only, while the smooth opposite surface does not cut. It is usually connected to a suction tube. These blades come in various sizes and configurations. This blade allows for simultaneous cutting and removal of cut tissue by suction.
3. Handpiece: Which is a portable micromotor. It derives its power supply from the console. The blade is attached to the shaft of the hand piece.

Advantages of microdebrider:
1. It cuts and removes tissue
2. Suction applied holds the tissue to the blade facilitating their cutting
3. Microdebrider is useful in performing polypectomy surgeries in the nose. It causes minimal trauma to normal turbinate tissue. Since it cuts on one side only, the opposite side is not traumatized. Since there is no raw area on the opposite side the incidence of post op synechiae formation is minimized.

Image showing the console
You can see a video of debrider in action: