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A headrest for head and neck surgery can be fashioned from foam packing material (Styrofoam) or a piece of foam cushion or mattress. Use a 25 cm × 25 cm × 10 cm piece and hollow out the middle so that it is only one-third of the original depth. This space is for the patient’s head. The foam material will provide traction to keep it in place on the operating room (OR) table.1 This headrest can also be used as a sleeping pillow if the individual needs, or wants, to be only on his or her back.


Most of the regional nerve blocks useful for ear, nose, and throat (ENT) procedures are discussed in Chapter 26.

Paravertebral Block

To relieve most or all orofacial pain in adults, use a simple paravertebral block. This is an extremely safe procedure, because the injection is made with a 1.5-inch-long, 25-gauge needle. Inject 1.5 mL of 0.5% bupivacaine into the paravertebral musculature on both sides, 1 inch lateral to the seventh cervical spinous process. Bupivacaine provides good pain relief within 15 minutes for adults with toothache (odontalgia), mandibular fractures and dislocations, temporomandibular joint (TMJ) syndrome, ocular pain, facial pain from a variety of other causes, and headaches.2,3



If an otoscope is not available, use an ophthalmoscope to look through any type of speculum into the ear canal. Objects that can substitute for a speculum include a pen casing (cut the tapered point off a little and smooth it), a 1-cc syringe barrel with the end cut off and smoothed, a nasal speculum (be careful not to put it in too far), and similar objects. Note that many late-19th century otoscopes looked no different than modern nasal speculums. They used a direct or an indirect (head mirror) light source.4

Foreign-Body/Cerumen Removal

Knowing how to remove foreign bodies from an ear can save time and resources. There is no evidence to support choosing one method over another in most cases, and many different techniques are available. It is also useful to know which cases may need to go to the OR to have foreign bodies removed under sedation. The most difficult foreign bodies to remove are spherical objects, those in contact with the tympanic membrane (TM), and those that have been in the ear for >24 hours.5 Most foreign bodies can be removed using irrigation, dissolution, suction, glue, or by other physical means. The removal of insects and metal objects requires special techniques.


Current sedation techniques (see the “Procedural Sedation” section in Chapter 16) make it safe to administer sedation to both adults and children before undertaking what ...

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