DR CLARK ROSEN INSTRUMENTS FOR PHONOMICROSURGERY
Director - University of Pittsburgh Voice Center
The Eye and Ear Institute
""These are the essential set of instruments that I use for all my phonomicrosurgery procedures. These instruments allow the surgeon to palpate vocal fold pathology, elevate microflaps and dissect sub-epithelial pathology from the vocal folds. These instruments are required to start the learning process of performing high-magnification, precise, conservative phonomicrosurgery.""
COMMENTS FROM DR. RICARDO CARRAU ON OUR ""LOW PROFILE"" UNIVERSAL CLIP APPLIER
Ligation of the sphenopalatine artery
The middle turbinate (MT) has been medialized to allow the simultaneous passage of the endoscope and dissecting instruments into the middle meatus. A naso-antral window has been opened, enlarging the natural ostium of the maxillary sinus, and has been extended posteriorly to expose the posterior wall of the antrum (PWA). The sphenopalatine artery with its anterior and posterior branches have been identified as it exits the pterygosphenopalatine fossa (PTF) and enters the nose. For purposes of the illustration, the artery has been dissected in the pterygopalatine fossa by removing part of the posterior wall of the antrum. In most instances, however, the exposure of the SPA within the PTF is not needed. After the main trunk is identified and mobilized, the adjustable clip applier (S.50.210) is used to apply a medium-size vascular clip through the middle meatus. Whenever possible, the posterior nasal artery and anterior branches are also clipped.
COMMENTS FROM DR.SETLIFF ON OUR IMPROVED PEDIATRIC BACKBITER
The retrograde approach to the uncinate process, first proposed by Dr.David Parsons, is an important step in my minimally invasive transition space surgical approach for endoscopic sinus surgery.
The approach demands a small, yet sturdy backbiter S.50.272 with a tapered blade. Without this essential step, the complete marsupializetion of the ethmoidal infundibulum cannot be done.
The most recent design of Instrumentarium meets all my requirements and insures a positive experience for the sinus surgeon who demands the certain identification of the maxillary sinus ostium. It can also be helpful in surgery of an intra-turbinate sinus (concha bullosa). There have been no failures of the instrument, in hundreds of sinus cases, in my hands.
COMMENTS FROM DR. SETLIFF ON OUR SINUS INJECTION SHEATH
Trauma to nasal septum and /or lateral nasal wall during intra nasal injection for endoscopic sinus surgery insures a troubled start. The endoscope is likely to be soiled, and bleeding can otherwise compromise the surgery.
The sinus injection sheath S.50.100 from Instrumentarium a quite easy to use, effective and reliable device which, by contrast enable the sinus surgeon to avoid the pitfall mentioned above.
It also has enough rigidity to serve as a light ""pusher "" to access the desired injection sites. Overall, it is a valuable addition and enhances the prospects of a positive start and a successful outcome.
COMMENTS FROM DR.CHARLES R. POTTER ON OUR UP-TURNED BACKBITER
The original version of the pediatric backbiter requires a 180° rotation after insertion of the instrument before engaging the uncinate process. The down-turn of the tip requires medial angulation of the shaft with use and makes it difficult to reach relatively lateral uncinates without impacting either the septum or the ""anterior buttress "".
The up-turned version is inserted at the same angle as it is used and thus avoids the 180° rotation. It curves quite naturally around the buttress without impacting the anterior septum during use. It will reach the uncinate even with hypoplastic maxillary sinuses. In fact, it has not failed in over a thousand consecutive antrostomies.
Both versions were made available to the dozen ENT surgeons in our area at the same time. Given this objective choice without having ""gotten used "" to either version, every attending and even the residents universally preferred the up-turned modification (S.50.273).
The up-turned version, in summary, retains all of the advantages of the original, is easier to use, and fits the anatomy better.
SEEKERS DR. DAVID S. PARSONS
These 90-degree blades are designed to be placed into the maxillary sinus ostia for enlargement of middle meatus antrostomies (MMA). The blade which cuts away from the surgeon is designed to be rolled into the natural ostium. A sawing motion can then be used to cut the superior portion of the fontanel back to the accessory ostium or to the posterior aspect of the fontanel. The blade which cuts toward the surgeon is designed to be placed within an accessory ostium, cutting the fontanel anteriorly to include the natural ostium.
This is designed to allow the surgeon to dissect the lateral and medial mucosa from the lower uncinate bone remnant following creation of the ""window "". Careful dissection will free the bone for removal, leaving the mucosa intact so that the final common pathway will not be injured. The opposite end is the standard ball tip seeker.
This acutely angled seeker is designed to be rolled into the infundibulum from the posterior aspect of the uncinate process. When pulled anteriorly, its tip usually reaches the anterior extent of the infundibulum. A vertical motion should free any adhesions which are present and obstructing the infundibulum. Pulling the probe anteriorly will move the uncinate medially, preparing it for a backbiter blade (S.50.272). The opposite end of the instrument is an elongated ball tipped seeker, used for those difficult to reach areas, such as a hypoplastic maxillary sinus.
This suction tip has a 90° blade which is anchored firmly so as to not be fractured off the instrument. The suction allows the surgeon to keep the field clear while simultaneously palpating or moving tissue including thin bone or mucosa. It is specifically designed for very delicate dissection.
KAVANAGH OTOLOGIC ""HAND STABLE TM "" INSTRUMENTS
The Kavanagh Otologic "" Hand Stable TM "" Instruments comprise a wide variety of forceps, micro-scissors and crimpers all specifically designed to provide stabilization of the otologist 's hand during surgery.
The working action of standard surgical middle ear instruments is the lower most instrument handle. This handle is activated by using the surgeon 's third and fourth digits. When using standard instruments, the upper-most instrument handle must be held still by the thumb and not moved while the lower handle is moved toward it. Thus, the surgeon cannot stabilize his operating hand during ear surgery.
The problem is most pronounced during stapes surgery when trying to crimp the prosthesis. The otologist will often stabilize his surgical hand with his opposite hand and lock the speculum in place with a speculum holder.
Instrumentarium 's newly designed "" Hand Stable TM "" instruments have a "" reverse action "" and eliminate this cumbersome surgical exercise and free the otologist 's opposite hand to help stabilize the prosthesis. The third and fourth digits can be kept still, resting on the patient, while the surgeon 's thumb activates the instrument.
KAVANAGH MIDDLE CRANIAL FOSSA ""HAND STABLE TM "" INSTRUMENTS
The Kavanagh Middle Cranial Fossa Hand Stabilization Instruments comprise a wide variety of forceps, micro-scissors and crimpers all specifically designed to provide stabilization of the neurotologist's hand during surgery.
The working action of standard surgical middle ear instruments is the lower-most instrument handle. This handle is activated by using the surgeon's third and fourth digits. When using standard instruments, the upper-most instrument handle must be held still by the thumb and not moved while the lower handle is moved toward it. Thus, the surgeon cannot stabilize his operating hand during ear surgery.
Instrumentarium 's newly designed "" Hand Stable TM "" instruments have a "" reverse action ""and eliminate this umber some surgical exercise and free the neurotologist 's opposite hand to help stabilize the prosthesis. The third and fourth digits can be kept still, resting on the patient, while the surgeon 's thumb activates the instrument.
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