Ear, Nose, and Throat (ENT) Surgery: Tympanoplasty, Sinus Endoscopy, and Tonsillectomy

Ear, Nose, and Throat (ENT) Surgery Overview

ENT surgery encompasses a wide range of procedures involving the ear, nose, throat, and related structures of the head and neck. As a surgical technologist in the scrub role, you must know the anatomy, the instrument sets, and the specific safety responsibilities for each procedure. This lesson focuses on three common ENT procedures: tympanoplasty, functional endoscopic sinus surgery (FESS), and tonsillectomy.

Tympanoplasty

Tympanoplasty is the surgical repair of a perforated tympanic membrane (eardrum) and may include reconstruction of the ossicular chain (the small bones of the middle ear). The procedure is performed under general or local anesthesia and often requires magnification because the operative field is extremely small.

Surgical microscope setup is a critical scrub responsibility. Before the surgeon approaches, the sterile field must include a draped microscope. You drape the scope arm using a manufacturer-approved sterile microscope drape, taking care not to contaminate the eyepieces or the lens. Follow the written draping protocol step by step, then confirm positioning so the microscope can be moved smoothly over the patient's ear without reaching across the sterile field. Improper draping can force a time-out and delay the case—or, worse, cause a breach in sterility.

The tympanoplasty instrument set typically includes micro ear instruments: picks, hooks, and curettes scaled for middle-ear work; a self-retaining speculum; an ear speculum holder; Rosen and Sickle knives; alligator forceps; and suction irrigators sized for the canal. Graft material (commonly temporalis fascia or perichondrium) is harvested through a small postauricular incision; instruments for harvest and preparation are kept separate. Patient safety note: micro instruments are delicate and must be handled and counted with extreme care—a retained micro instrument in the ear canal is a serious patient safety event.

Functional Endoscopic Sinus Surgery (FESS)

FESS uses rigid nasal endoscopes to visualize and open the sinus drainage pathways under direct camera-guided vision. It treats chronic sinusitis, nasal polyps, and related conditions. The surgical technologist must be proficient with the endoscopy tower as well as the specialized sinus instrument set.

Endoscopy tray contents for FESS commonly include: rigid Hopkins-rod nasal endoscopes (typically 0°, 30°, and 70° angled lenses); Blakesley forceps (straight and angled) for tissue removal; Stammberger backbiting punches; Kerrison rongeurs; Cottle elevators and freer elevators; nasal specula; suction-irrigation cannulas (e.g., Frazier-tip suctions); through-cutting forceps; and powered shaver (microdebrider) handpieces with disposable blades. The scrub must be able to identify each instrument by name and state its specific function.

Safety considerations for FESS: The orbit and skull base are in close proximity to the operative field. Maintain instrument counts meticulously. Endoscope lenses must be defogged and white-balanced before handing to the surgeon. Never force a rigid endoscope; micro-trauma to the turbinates can cause bleeding that obscures the field. Powered shaver blades are sharp—handle the handpiece carefully and confirm the blade guard is engaged when not in active use.

Tonsillectomy

Tonsillectomy is the surgical removal of the palatine tonsils, most often performed under general anesthesia with the patient supine and the head extended using a shoulder roll. A Crowe-Davis or McIvor mouth gag is placed to hold the mouth open and expose the oropharynx. The scrub must be ready to pass instruments efficiently because bleeding control is time-sensitive.

The tonsillectomy instrument set includes: a Crowe-Davis or McIvor mouth gag with tongue blade; Hurd tonsil dissector and pillar retractor; White tonsil-seizing forceps; Allis forceps; Metzenbaum and straight Mayo scissors; tonsil snare; suction (Yankauer and Frazier-tip); electrosurgical pencil or bipolar forceps; and tonsil sponges (counted). A headlight is used by the surgeon; the scrub ensures the light source cord is secured out of the sterile field pathway.

Airway safety is the top priority in tonsillectomy. The anesthesia provider is at the head of the bed managing a shared airway. Communicate clearly before passing any instrument near the patient's face. Sponge counts are critical—a retained sponge in the pharynx can cause airway obstruction. Count all throat packs and tonsil sponges aloud with the circulator before and after use.

Scrub-Role Responsibilities Across ENT Cases

• Complete a thorough instrument count with the circulator before incision and at closing per facility policy.
• Organize the back table and Mayo stand so instruments are accessible without reaching over the sterile field.
• Anticipate the surgeon's next instrument based on the step of the procedure.
• Keep the endoscope lens clean with a warm saline-moistened sponge.
• Report any instrument that appears damaged or non-functional to the circulator immediately—do not pass a defective instrument to the surgeon.
• Know your facility's policy for specimen handling; sinus tissue and tonsillar tissue are routinely sent to pathology.

Preparing for the CST Exam

The NBSTSA CST examination tests your knowledge of surgical instrumentation, specialty procedures, and patient safety across all surgical specialties. For ENT, expect questions on instrument identification, microscope use, airway management considerations, and count procedures. Mastering the tray-ID skills practiced in this lesson directly supports exam readiness.