CIS SELF-STUDY LESSON PLAN Lesson No. CIS 271 (Instrument Continuing Education - ICE) Sponsored by:

Tonsillectomy & Adenoidectomy Instrumentation JON WOOD, BAAS, CST, CRCST – CLINICAL EDUCATOR, IAHCSMM

Instrument Continuing Education (ICE) lessons provide members with ongoing education in the complex and ever-changing area of surgical LEARNING OBJECTIVES instrument care and handling. These lessons are 1. Identify common instruments found in a tonsillectomy and adenoidectomy tray designed for CIS technicians, but can be of value 2. Review the key inspection areas for instruments in a tonsillectomy and to any CRCST technician who works with surgical instrumentation. adenoidectomy tray 3. Discuss the function of tonsillectomy and adenoidectomy instrumentation during a Earn Continuing Education Credits: procedure Online: Visit www.iahcsmm.org for online grading at a nominal fee.

By mail: For written grading of individual lessons, nstrument inspection and testing needs and preferences. The following is a send completed quiz and $15 to: is one of the core responsibilities list of common T&A instrumentation: Purdue University - Online Learning of the Central Service/Sterile Ernest C. Young Hall, Room 526 155 S. Grant Street Processing (CS/SP) technician. • Backhaus towel West Lafayette, IN 47907 ProducingI patient-ready instrumentation • is significant to any successful • White tonsil clamp (similar to a curved Scoring: Each quiz graded online at www.iahcsmm.org or through Purdue University, surgical procedure. It is essential Allis clamp) with a passing score is worth two points (2 contact for an instrument specialist to have • Schnidt tonsil hours) toward your CIS re-certification (6 points) or the knowledge and skills to identify • St. Clair-Thompson adenoid forceps CRCST re-certification (12 points). commonly-used instrumentation, • Foerster-Ballenger sponge holding More information: IAHCSMM provides online recognize important inspection areas forceps grading service for any of the Lesson Plan and understand the functionality of each • Baum tonsil varieties. Purdue University provides grading services solely for CRCST and CIS lessons. Direct instrument. This lesson will describe • any questions about online grading to IAHCSMM commonly-used instrumentation found • at 312.440.0078. Questions about written in a tonsillectomy and adenoidectomy • #7 knife handle grading are answered by Purdue University at 800.830.0269. (T&A) tray, review vital inspection areas • Fisher tonsil knife and dissector on T&A instruments and explain how • Hurd dissector and Pillar instruments are used during a T&A • Wieder tongue depressor/retractor procedure. • Meltzer triangular punch (straight or curved) OBJECTIVE 1: Identify common • Yankauer instruments found in a tonsillectomy and • Andrews-Pynchon suction adenoidectomy tray • Laryngeal mirrors (multiple sizes) Several variations of instrumentation • Tonsil snare can be found within the T&A tray. The • Adenoid (multiple sizes) variation of instrumentation can differ • Mouth gag with blades (Dingman, from healthcare facility to healthcare Jennings, Davis or McIvor with facility and is generally selected based multiple size blades) upon the surgeon’s specific procedure • Medicine cup CIS SELF-STUDY LESSON PLAN

Figure 1: A. McIvor Mouth Gag B. St. Clair-Thompson adenoid forceps C. Fisher tonsil knife and dissector

OBJECTIVE 2: Review the key inspection ensure instrumentation is cleaned areas for instruments in a tonsillectomy properly. and adenoidectomy tray Testing instrument functionality is Instrument inspection and testing is also an important step in the assembly an important step in the instrument process. Before testing functionality, assembly process. In the assembly phase, it is important to always review the instruments should be inspected for manufacturer’s instructions for use (IFU). cleanliness and tested for functionality. The T&A tray contains several types of Figure 2: Key inspection points for forceps Inspection is important because after instrumentation with different inspection the assembly phase the instrumentation areas, including ringed forceps, forceps, • Ratchet – The part of a surgical will not be checked again until after scissors, suction and more. When testing instrument that locks the handles in sterilization, which will be at the point ringed forceps, it is important to inspect place of use. Discovering dirty, damaged or and test the following areas: missing instrumentation at the point • Jaws – Two or more opposable parts The jaws of the ringed instruments of use can cause delays or other serious that open and close; used for holding should align and approximate when problems that may result in adverse or crushing something between them closed. The serrations in the jaws patient outcomes. • Serrations – Parallel grooves in the should be inspected for cleanliness and At first glance, instrumentation may jaws of surgical instruments damage. The box lock can be one of the appear to be clean, but closer inspection • Box lock – Point where the two jaws most challenging areas to clean on the of the entire instrument may reveal or blades of an instrument connect instrument. Residual bioburden in the areas that were not cleaned properly. and pivot box lock can damage the instrument Tools such as lighted magnifiers, digital • Shanks – The straight, narrow part of a and make it difficult to open and close. cameras, microscopes and borescopes tool that connects the working part Stress fractures are commonly found in can improve visualization and help with the handle. the box lock area, which can be caused CIS SELF-STUDY LESSON PLAN

It is essential to test the sharpness of scissors. Red testing material should be used for scissors 4.5” and larger, and yellow testing material should be used for scissors 4” or smaller. Before being considered functional/acceptable, scissors must demonstrate the ability to cut through the testing material cleanly several times. The suction device is an important instrument used in a T&A procedure. The primary function of the suction is to remove blood, body fluids and irrigation solution from the operative site. Visual Figure 3 inspection of the inside of the device is just as important as inspecting the outside of the device. Tools, such as the borescope, can be used to visually inspect the innerworkings of the device. Other important instrumentation on a T&A tray includes curettes and mouth gags. Curettes should be inspected for nicks and burrs in the blade area and tested for sharpness using a plastic dowel rod. See Figure 3. The mouth gag has two main areas of interest for inspection. First, when inspecting the spring-action locking mechanism that secures the blade while in use, the spring should move freely without hesitation. Second, the silicone guard should be intact without tears or gouges, and the screws should be secure and not loose. See Figure 4.

OBJECTIVE 3: Discuss the function of tonsillectomy and adenoidectomy instrumentation during a procedure After the patient is anesthetized, the Figure 4 patient is draped for the procedure. A head drape is used and secured with by over use or improper sterilization in needle holding forceps have tungsten a towel clamp. After the patient is the closed position. The shanks should carbide jaw inserts (indicated by gold fully draped, a mouth gag retractor is be symmetrical and undamaged. The ring handles) that can be removed when used to open the mouth, which is the ratchet area should be tested to ensure they become worn from use or damaged. operative site, and to secure the tongue. the instrument stays closed after being Scissors should be inspected in the It is important that the mouth gag stay ratcheted. If the ratchet springs opens same manner as ringed instruments (this in place throughout the procedure; while testing, the instrument is damaged is done by visually inspecting the key therefore, checking the spring function and should be sent for repair. Some areas previously outlined in this lesson). and lock mechanism is critical. The CIS SELF-STUDY LESSON PLAN

silicone inserts or tubing help protect bleeding. The ratchet area of the sponge blood, body fluid and smoke from the the patient’s teeth, gums and lips from holding forceps should be tested to surgical site. After the tonsil areas have injury. Loose screws on the mouth gag ensure it stays in place while holding the stopped bleeding and the tonsillar spaces retractor have the potential of dislodging sponge. appear dry, the adenoid sponges are and falling into the patient’s esophagus or Next, the tonsillectomy procedure removed, and a suction electrocoagulator trachea. is performed. The tonsillectomy can and mirror are used to complete the Once the mouth gag is in place, a red be performed using several different procedure. rubber is placed in the nose and techniques, such as “hot knife” which passed through the nasopharynx into uses electrocautery, coblation or “cold Note: There are several variations in the the back of the mouth. The red rubber knife,” which uses a #12 blade and the T&A procedure. Objective 3 covers some catheter is retrieved and both ends are #7 knife handle. During the “cold knife” but not all surgeon-specific instrument clamped with a tonsil forceps. This technique, an Allis clamp or White preferences or procedure styles. maneuver retracts the soft pallet and tonsil clamp, which is similar to a curved allows for access and better visualization Allis clamp, grasps the tonsil tissue. Conclusion of the adenoids. The forceps holding It is important to inspect the jaws of Procedures such as the T&A could not be the red rubber catheter must stay in the the clamp to confirm it can hold tonsil successful without the knowledge of the locked position to keep the soft pallet tissue and withstand the back-and-forth CS/SP technician. CS/SP technicians who retracted. Testing the ratchet of the tonsil twisting movement that is required understand the importance of instrument forceps will help ensure the instrument during the tonsil dissection. The #7 knife inspection and testing and are familiar stays locked. handle and #12 blade are used to make with how instrumentation is used during During the adenoidectomy portion the initial cut from the superior pole a procedure gain a better understanding of the procedure, a laryngeal mirror to the anterior tonsil pillar. The Fisher and are better equipped to prevent is used to visualize the adenoid tissue, tonsil knife and dissector is then used to adverse patient outcomes. which is located on the posterior wall help further dissect tonsil tissue from the of the nasopharynx. Mirrors should tonsillar capsule. Nicks and burrs in the Resources be checked for stains and cloudy spots Fisher knife can also rip and tear tissue International Association of Healthcare Central that could impede visualization. If a instead of cleanly dissecting tissue. Service Materiel Management. Central Service mirror is cloudy or damaged, it should A tonsil wire snare is then placed Technical Manual, Chapter 10 Surgical be removed from the tray and replaced. around the tonsillar tissue and the tonsil Instrumentation, pp.179-201. 2016. Once the adenoid tissue is visualized, it is removed. Testing of the snare is vital can be removed with either an adenoid in this phase. The wire from the snare Alexander’s. Care of the Patient in , , microdebrider or suction should pass smoothly and completely Chapter 25 Pediatric Surgery, P.1127. 2011. electrocoagulator. When using the through the shaft of the snare, without adenoid curettes, it is important that hesitation. Snare wire that does not the curette blade is sharp and free of pass completely through the shaft nicks and burrs that can rip and tear can cause excessive bleeding and be tissue instead of cutting tissue. After the difficult to remove, which can cause a adenoid tissue is removed, any remnants delay during this critical portion of the can be removed by using a St. Clair- procedure. The tonsil space can then be Thompson forceps or Meltzer triangular packed using the tonsil sponge and the punch. These instruments should be procedure is repeated on the next tonsil. sharp, so tissue can be cut cleanly After both tonsils are removed, excess without further ripping or tearing bleeding is then controlled with a suction of tissue. electrocoagulator. A Hurd dissector and After the adenoids are removed, Pillar retractor can be used to retract the sponge holding forceps are used tonsillar pillar and improve visualization, with radiopaque sponges to pack the in addition to suction with a Yankauer nasopharynx area and help control or Andrews-Phychon suction to remove CIS Self-Study Lesson Plan Quiz - Sponsored by: Tonsillectomy & Adenoidectomy Instrumentation Lesson No. CIS 271 (Instrument Continuing Education - ICE) • Lesson expires January 2022

1. Which of the following instruments 6. Manufacturers’ instructions for use 11. Tungsten carbide inserts can be found would not be found in a tonsillectomy are not always important to review before on which type of instrument? and adenoidectomy tray? testing instrument functionality. a. Needle holder a. Andrew-Pynchon suction a. True b. Retractor b. Balfour retractor b. False c. Forceps c. Hurd dissector and Pillar retractor d. Curette d. Fisher tonsil knife and dissector 7. Which is the point where the jaws or blades of the ringed forceps connect 12. Which color testing material should be 2. Which of the following instruments and pivot? used when testing the sharpness of would you expect to find multiple sizes of a. Jaws scissors 4” and smaller? in a tonsillectomy and adenoidectomy b. Box lock a. Orange tray? c. Shanks b. Yellow a. Hurd dissector and Pillar retractor d. Ratchet c. Red b. Fisher tonsil knife and dissector d. Brown c. Adenoid curettes 8. Two or more opposable parts that d. #7 knife handle open and close and are used for holding 13. During the draping process, which or crushing something between them instrument should be used to secure the 3. All tonsillectomy and adenoidectomy best describes which part of the ringed head drape? trays are the same, regardless of the forceps? a. Sponge holding forceps healthcare facility. a. Jaws b. Needle driver a. True b. Box lock c. Schnidt tonsil forceps b. False c. Shanks d. Towel clamp d. Ratchet 4. After instruments are inspected for 14. A red rubber catheter is used during the cleanliness and functionality in the 9. Which part of a locks adenoidectomy procedure to retract the: assembly area, instruments typically will the handles of the ringed forceps in a. Superior pole not be checked again until: place? b. Anterior tonsil pillar a. Just before sterilization a. Jaws c. Trachea b. They are at the point of use b. Box lock d. Soft pallet c. After they are sterilized and in clean c. Shanks assembly d. Ratchet 15. During the adenoidectomy portion of the d. The instruments are in the procedure, which of the following is used decontamination area 10. Stress fractures are commonly found in to visualize the adenoid tissue? which area on the ringed forceps? a. Hurd dissector and Pillar retractor 5. Which of the following is a tool that can a. Jaws b. Laryngeal mirror be used for improved visualization b. Box lock c. Fisher tonsil knife and dissector during the inspection process? c. Shanks d. Adenoid curettes a. Leakage tester d. Ratchet b. Demagnetizer c. Borescope d. Heat sealer

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