Naomi White, RN

OR nursing I 8 in otomicrosurgery

The OR nurse who works in otomi- crosurgery must have an interest in small things and be able to work as a team member. She must have an acute awareness of the nature of working in a tiny field with magnified movement.

Not every nurse can do this satisfac- torily. Among OR nurses, there is a need to recognize the uniqueness of each specialty, especially among those responsible for assignments. The philosophy that every operating room nurse needs to be capable of doing every procedure well is nonsense. Although every OR nurse needs knowledge of all surgeries, she should not be expected to excel in each. Otomicrosurgery is one specialty that requires the assistance of a specialist nurse.

It is a challenge to assist in pro- cedures where you are unable to see. One must have the ability to form mental images and to think as the surgeon thinks. It is much like work-

Naomi White, R N , is team leader of the otolaryngology department at Pres- byterian Hospital, Oklahoma City. A graduate of the University of Ok- lahoma School of Nursing, Mrs White presented this paper at the 1975 AORN Congress.

ing blind. It takes a team player to be either a good scrub nurse or circulator, or a good surgeon when working through a microscope in the delicate area of the middle ear, a n area that is about the size of the eraser of a pencil. These procedures include the stapedec- tomy, various types of tympanoplasty procedures to reconstruct either the tympanic membrane or ossicular chain, or both, and mastoidectomy.

Psychological preparation. As with the blind, psychological preparation of the hard-of-hearing patient takes on added importance. At the time of his visit to the physician’s office, the pa- tient has been told what to expect con- cerning surgery. The surgeon explains the hearing problem, what surgery he will perform, and the chances for hear- ing improvement.

Many times the patient does not fully comprehend this information partly because of his hearing problem and often because of the excitement of the moment. He may forget or not understand what is being said. There- fore, a preoperative visit is desirable by an OR nurse who can answer ques- tions the patient asks.

During her visit, the nurse should also tell the patient what to expect postoperatively. She should explain

AORN Journal, December 1975, Vol22 , No 6 889

that he will need to stay in bed until the preoperative medication wears off. He is instructed not to lie on the oper- ated ear for 24 hours because pressure may cause more bleeding. A pillow can be placed beside his head to remind him not to turn on the operative side.

Following stapedectomy, the patient may experience dizziness and he should be instructed to move his head slowly as if he had a glass of water on his head. He will need to know he will experience a temporary hearing loss because of packing and possible blood clot in the ear canal and be reassured that hearing will return when the pack is removed. These verbal in- structions are more effective if re- inforced by being printed on a card and sent to the room with the patient.

Preparation of the operating room. It is seldom too early and often too late to begin arranging the room. The room must be in order for the surgeon to work. He should not have to wait until the cautery is plugged in, the suction foot pedal is properly placed, or a headlight taken out of the box. If scheduling permits, the room should be arranged and ready for opening of the sterile setup one hour before the scheduled operative time. The scrub nurse usually needs 20 to 30 minutes t o prepare the sterile field.

The following equipment is needed for ear surgery:

0 electric table 0 rolling chair 0 operating microscope 0 square table (The four legs make

it sturdier for the surgeon to rest his arms on while drilling on tiny ossicles for reconstruction.)

0 cautery 0 drills with foot-pedal control. The

Stryker air drill is generally used for mastoid surgery although some surgeons prefer the Jordon Day drill. The Kerr electric drill

is used for stapes surgery and to sculpture ossicles for reconstruct- ive procedures.

0 suction foot pedal to interrupt wall suction. This is important to allow the surgeon to grasp or re- lease anything at will such as the edge of a fascia graft that he is trying to put in.

0 headlight to see up and under skin while taking a fascia graft.

The position of the equipment will vary depending on which ear is to be operated. It is convenient to have the operating table perpendicular to the back instrument table; however, it cannot always be this way because of the location of the anesthesia panel coming from the ceiling, which varies from room to room. When arranging the equipment, care must be taken to place cords and tubing away from the chair and feet of the surgeon.

For procedures under general nnes- thesia, the microscope can be brought in from the head of the table, neces- sitating a sterile cover for the micro- scope pole.

The scrub nurse stands directly a- cross the table from the surgeon, with her Mayo in place from that side. The back table is positioned so that it is accessible to the nurse. On mastoidec- tomies, the square table is placed near the patient table. After the incision is made and the retractor in placz, the square table and the Mayo are ex- changed.

For surgery performed under local anesthesia, the Mayo is placed to the right of the surgeon. During a pro- cedure on a right ear, the Mayo is positioned over the abdomen of the pa- tient. The microscope is brought in from the opposite side at the corner of the table. The circulator sits on the opposite side, which is considered the nonsterile area. For a left ear pro- cedure, the Mayo is placed at the head

890 AORN Journal, December 1975, Vol22, No 6

of the table, and low, making passage of instruments to the surgeon’s right hand more convenient. For left-handed surgeons, this setup may be reversed.

If surgery is done under local anes- thesia, the circulating nurse should sit beside the patient literally holding his hand. This not only allows the nurse to record vital signs but reassures the patient that someone is with him if he experiences dizziness or a sense of fall- ing. Oxygen should be available and monitoring with the electrocardiogram monitor is desirable.

Sterile instrument setup. A break in technique could result in infection to the inner ear or meningitis because vestibular fluid under the footplate is

continuous with cerebral-spinal fluid. It is important to rinse powder from gloves before handling instruments. Powder and lint act as foreign bodies, and it is surprising to seL under the miscroscope the amount that clings to gloves. The nurse must wash her hands again after gloving the surgeon or touching his gloves on the back ta- ble.

To eliminate lint in the sterile field, commercial drapes are available to cover the back table, top of the square table, and the Mayo stand. Foam- laminated ear drapes are also avail- able in several sizes.

The arrangement of instruments on the back table is an individual matter,

Fig 7. Middle ear instruments on Teflon instrument holders.

Fig 2. Small square instrument table arranged for a mastoidectomy.

AORN Journal, December 1975, Vol22 , No 6 891

however, it is best to have a uniform setup for the Mayo stand. In teaching, I say, “First you learn my way, and when you know what you are doing, then do it however you wish. I have a reason for doing it this way, but if it makes more sense to you another way, then change it.”

The arrangement that works for me is to put the long instruments in two rows beginning with knives, then in the order they will be used. Begin the second row with the various picks. Put forceps in a row, with the more fre- quently used ones nearer the surgeon’s hand. In keeping with a lint-free field,

Fig 3. lnstrument set prepared to sculpture

an ossicular bone graft.

we use Teflon instrument holders. These holders keep the ends of the instruments in the air and prevent them from catching on anything. In addition, they are white to show the tips (Fig 1).

The small square table is used to hold instruments for the mastoid inci- sion, retractors, irrigation, and graft instruments (Fig 2). After the incision is made and drilling begun, these in- struments are replaced with the set to trim the fascia graft, and a set to sculpture an ossicle (Fig 3).

We use a small green Teflon disc to keep absorbable gelatin sponge lint

Fig 4. Method of compressing Gelfoam and instruments to cut

Gelfoam.

892

Fig 5, above. Nurse using a forcep and small scissors to hold and cut Gelfoam.

Fig 6, left. Nurse cutting Gelfilm onto Teflon disc.

Fig 7. Petri dish with wet cotton pledgets for moist tissue chamber.

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and powderfree during transport. If the sponge is to be used flat, it is left partially inside its inner package and compressed or ironed against a hard, flat surface with the bottom of a medicine glass. Sponge used fluffy is kept moist with Tis-U-Sol (Fig 4).

When cutting Gelfoam and Gelfilm, handle it with forceps. The sponge should never be touched with your fin- gers. Keep in mind that these sub- stances may be left inside the ear and you do not want any lint or powder on them. For the same reason, handle all tissue with forceps (Fig 5 ) . Gelfilm may be cut while still in the inner package. It is brittle and frequently breaks. It is cut in ovals and also un- touched by human hands (Fig 6 ) . Wet Gelfoam squares are placed in a Petri dish. Three small pieces of cotton moistened with Tis-U-Sol are placed into another Petri dish to receive tis- sue and fascia graft (Fig 7). The tissue graft should never be floating in solu- tion. The lid should be kept on as much as possible to prevent the tissue from getting too dry. Tis-U-Sol, a more physiological solution than normal saline solution, is also used for irriga- tion. All irrigation solutions are kept at body temperature.

The nurse needs good eyesight as he or she has to distinguish the difference among the tips of these tiny in- struments, especially during the pro- cedure when the room is often dimly lit. The handles of the picks may be marked to make it easier to tell right angle picks from right angle ex- cavators.

The scrub nurse should wipe the end of each instrument after use with a 4” x 4” sponge moistened with Tis-U-Sol or an instrument wipe. Do not use the powdery water from the splash basin. The sponge or wipe must be changed frequently; however, the sponge is not

moistened when the surgeon is prepar- ing a perichondrium graft for the stapes procedure because any chemical on the graft may produce an adverse reaction in the footplate area in the healing process.

Supporting elements in an operating room prepared for ear surgery will in- clude:

1. A bone bank for ossicular trans- plants. Sterilize small bottles and store bones in 70% alcohol changed every two weeks. The donor’s name, hospital number, and date the bone was harvested are recorded. 2. Dental cotton balls, size #3, to absorb bleeding. These are made from long fibers that are less likely to leave cotton lint in the ear. 3. Oils and cleaning lubricant for the drills. 4. Nylon chiffon. We buy the mate- rial a t a fabric store and cut a neat, four-tailed pack for mastoid surgery packing. We prefer blue in color as it is easy to see to remove in the office. 5. A blue kitchen sponge. This is cut up in small pieces and placed inside the four-tailed pack for pres- sure. The pack is sterilized with instrument sets. 6 . Expandable dental sponge or Weck sponges. These are cut in a tear-drop shape, and a black silk suture is tied to the larger end. Then they are used for external ear canal dressings following stapes surgery. The use of black thread makes it easier for the surgeon to see the sponge to remove it in his office postoperatively. 7. Sterile toothbrushes to clean the ossicular bone grafts. These are gas sterilized. Surgical prep. The patient should be

brought to the operating room 20 to 30 minutes before the scheduled time of

894 AORN Journal, December 1975, Vol22 , No 6

surgery. On arrival in the operating room, the patient may need to be re- assured. This is a crisis time for many and repeated instructions or explana- tions may be necessary.

In positioning the patient on the operating table, place him near the edge on the operative side, thus bring- ing the surgeon closer to his work. Place a pillow under his knees and tuck his arms in a t the sides. The head of the patient is a t the foot of the table allowing knee space for the surgeon. The anesthesiologist sits near the foot of the patient. To keep the machine out of the sterile field, he may need to extend the gas tubing. There is a screen for the drapes allowing the patient to see and get air.

In prepping, remember tha t the pa- tient may be sensitive about his ears and should be told when you are going to put warm water in his ear and shave around it.

The prep for a tympanoplasty or mastoidectomy is as follows:

1. Place cotton in ear canal. 2. Separate the hair with bandage scissors, marking the area to be shaved. Cut long hair closely. 3. Shave the hair around the ear about the width of the razor, or ap- proximately two inches. Lubricating

Fig 8. The patient’s ear after the sterile prep.

jelly works well to lather the area. It allows the razor to slide easily and keeps hair not included in the prep area out of the way. 4. Dry the area well, then slip tubular gauze over the head. Cut a slit in the gauze and pull around front and back to expose the ear. Tape the gauze cap in place with two-inch paper tape as shown in fig- ure 8. 5. Wearing a sterile glove, scrub the ear well with povidone-iodine soap. Do not let soap soak through the cotton into the ear canal as this is very painful if the patient has a perforated ear drum. 6. Saturate 4” x 4” sponges with povidone-iodine soap and place around and over the ear. Be careful to double 4” x 4”s under the ear l obpdon’ t just lay them on top. Leave the sponges in place 10 to 20 minutes until ready to drape. In prepping for a stapedectomy,

povidone-iodine soap can be poured into the ear canal because the patient has a good eardrum. If the drum needed to be repaired, the procedure would be scheduled a s tympanoplasty. There is no need to shave for stapedec- tomy.

Instrument care and cleaning. Ear

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Instructions after operations on the stapes

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Do not lie on the operated ear during the first 24 hours after surgery. You may lie on your back or the other side. After 24 hours, you may lie on the operated ear.

Stay in bed for the first 4 to 5 hours after surgery. When you get up, have someone with you. Be sure the head of the bed is elevated about 45 degrees for the first 4 to 5 hours after surgery.

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Do not blow your nose for three weeks. Any accumulation in the nose may be drawn back and expectorated through the mouth.

If you sneeze, keep your nose and mouth open when doing so.

Move your head slowly and only with a smooth motion to help prevent dizziness. Don't do any stooping or sudden turning. Get up slowly.

Do not be concerned with your hearing. It is very normal for the hearing to regress a few hours after surgery. It will be very distorted and poor for some time. Do not be discouraged over this. Frequently the hearing will be bad, but will continue to improve for many weeks after surgery.

Do not wash your hair for ten days-and keep water out of the ear canal for three weeks. A cotton plug placed in the canal and covered with vaseline will prevent water entering the ear while washing the face or taking a shower.

Obtain your antibiotic prescription at the nurses' desk at the hospital before leaving. Take these antibiotics regularly around the clock as directed unless allergic manifestations occur. Take with 1/z glass of milk. You will also have a

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prescription for dizziness to be taken if necessary.

You may change the outside cotton in your ear once or twice daily. Please use the sterile cotton given to you in the hospital. Wash your hands for 2 to 3 minutes with soap and water before touching your ear. If necessary, the external ear may be cleaned with cotton dampened with rubbing alcohol.

Call the office or the home telephone number below if you develop a cold or have an elevation in temperature above normal. Please call if you should have excessive pain or dizziness during the first few weeks following surgery.

Heavy work should be avoided for one week following surgery, but light work may be resumed as soon as dizziness subsides.

Avoid loud noises! (Tractors, machinery, hair dryers, any high-pitched sounds). If you work in a noisy environment, it is recommended that you avoid this noise for 8 weeks, or ask Dr about protection from sound with muffs.

Do not drive a car for a week following the surgery.

Flying is permissible after 1 week, but in commercial airplane only.

No swimming for 2 months. Avoid diving until advised.

Do not blow on musical instruments for 3 weeks.

Return to Dr- pack removed.

office to have your

Cards with these instructions are given to stapedectomy patients to reinforce verbal orders given during the preoperative visits.

896 AORN Journal, December 1975, Vol22, No 6

instruments a re so very delicate and require special handling. We prefer to handle and store these instruments on racks that fit the dry heat sterilizer oven trays. We insist on dry heat. Only in rare emergencies should they be “flashed.” Instruments become dis- colored and corrode more easily if allowed to stay wet for long periods of time. Inadequate cleansing or rinsing can also cause corrosion or discolora- tion. Never, never put these tiny in- struments in a big pan to slosh around. Handle them individually or in small groups and wash them in- dividually, being careful of the hooks on the small instruments. A right- angle pick will turn into a 45-degree pick after being caught onto a few threads of a 4” x 4” sponge. Use 4” x 4” sponges to dry the instruments. An upturned scrub brush serves to sup- port the ends of instruments after washing them by hand. A small ul- trasonic cleaner is ideal. The forceps may have to be taken apart and cleaned well and lubricated with silicone spray. Clean suction tips well.

The instruments must never leave the department. Supplies and in- struments such a s speculums, suction tips, hemostats, and retractors can be wrapped in sets and autoclaved. Small instruments should be stored in the ear room or department.

Knives are sharpened under the microscope about every six to eight months.

The microscope should be covered with a large plastic bag when not in use to keep it as dust free a s possible. The lens is cleaned with lens paper, never gauze 4” x 4” flats or abrasive cleaner. Handle the lens carefully and when changing the lens (for a different focal length), hold one hand under the other to catch the lens if it slips. When the observer tubes are removed, cover

the opening quickly so dust and lint do not get inside.

Both the scrub nurse and circulator need to be flexible, alert, and able to anticipate the surgeon’s needs. The scrub nurse should pass instruments quickly and in a position ready to use so the surgeon does not have to move his eyes and then refocus to view into the microscope. She should place a n instrument in his hand in such a manner that he can immediately lower it into the speculum or cavity. Through attention to details and care- ful technique, the OR nurse who specializes in otomicrosurgery contri- butes greatly to the successful outcome

0 of the procedures.

Total joint replacement course for OR nurses “The role of the operating room nurse in total joint replacement” will be the topic of the instructional course to be presented for OR nurses by the Joint Implant Surgery and Research Foundation.

Two sessions are planned: Jan 17-18 at the Airport Marina Hotel, Los Angeles, and April 3-4 at the Fairmont Colony Square Hotel, Atlanta. The cost is $125.

The course will provide indepth coverage of the problems, protocols, and planning in total hip, knee, and shoulder replacements. Conducted by Charles 0 Bechtol, MD, and Louise Schlesinger, RN, the seminar will examine duties and responsibilities of OR nursing and technical personnel in such problems as infection control, handling of bone cement, care and assembly of instruments, and draping and gowning procedures in the laminar flow clean room.

The 16-contact hour course will include slides and motion pictures. An illustrated syllabus will provide each student with a record for followup study and use in inservice teaching.

AORN Journal, December 1975. V o l 2 2 , No 6 897