 Among the many clinical activities that you might assist with or perform, there are several sinus irrigation procedures. We will demonstrate the Pretz Displacement procedure for irrigation of the ethmoid sinuses and the anterolavage technique for irrigation of the maxillary sinuses. The Pretz Displacement is a simple but effective procedure which you probably will be called upon to conduct by yourself. There are several clinical situations which might lead a physician to prescribe a Pretz Displacement treatment. One typical situation might involve a patient with no previous history of sinusitis who a month or two after treatment for a bad cold and accompanying sinusitis is still complaining of discomfort and a post nasal drip. The discharge material is yellow or greenish indicating infection. The physician might diagnose the condition as residual infection in the ethmoid sinuses. An x-ray often shows a haziness of the ethmoid cells. These cells are located behind and to either side of the nose. From four to seven cells are found on each side of the medium. The physician might prescribe antibiotics and Pretz Displacement irrigations every two to three days for ten days. The Pretz procedure is not prescribed for acute infections especially unilateral ones for fear of spreading the infection. The physician may perform the irrigation himself. It is not unusual for a busy physician to have a skilled technician perform the irrigation. After you have acquired enough experience you certainly may expect to be called upon to perform a Pretz Displacement on your own. One of your most important jobs will be to reassure the patient. You must explain the procedure fully and be sure that your patient understands exactly what she must do and what to expect. Your basic job is to sell the procedure to your patient. Explain that her sinuses will be cleaned out by introducing a medicated solution into one nostril and gently removing it through the other nostril while her head is back. Explain that there will be no pain but that the procedure will be wet and messy. Be sure to tell your patient that she can expect to feel much better after the irrigation. After you have reassured the patient you might use a Neosinephrine spray to shrink out the mucous membrane linings of the sinuses. Warn your patient about the bitter taste of the spray. Usually the irrigation solution is normal saline with 1-8% Neosinephrine. You will prepare the solution by mixing one part of 1% Neosinephrine with 7 parts of normal saline. The solution must be as close to normal body temperature as possible. You should warm the saline bottle prior to mixing under a warm water tap. When the membrane shrink, the ostea or normal sinus passages have a better chance of being open. Help your patient lie down on her back with her head lowered over the edge of the table. A straight line from ear to chin should be approximately vertical. Place towels around the neck and under the head to catch any solution overflow. When your patient is female and wearing a skirt or dress, drape her lower body. A surgical gown may be used for draping. The solution is instilled into one nostril with an aseptos syringe. The solution is not forced in but is merely allowed to flow in. A pretz bottle is used to apply suction to the other nostril. The nostril is sealed by the nasal tip. The other tube is connected to the SMR unit which supplies suction and contains a trap for overflow. You must instruct your patient to say KKK while the solution is flowing. This builds up a negative pressure in the nasal cavity which allows pressure in the ethmoid sinus cells to force material out. The first syringe full of solution that gets to the pretz bottle will contain mucus, probably yellowish-green. Some of this material should be retained for a culture. The material used for demonstration in this videotape is dyed egg white. Real mucus and pus will look something like it, but the color and consistency will vary. The procedure is continued, often with five or more syringes of solution, until the fluid coming into the pretz bottle is clear. When you complete the irrigation, tell the patient that some solution is still in her nasopharynx and that it will fall into her throat when she sits up. She need only spit it out or swallow it. The solution, incidentally, is virtually harmless and non-irritating, even to lung tissue. Usually your patient will feel fine after the procedure. Be sure to reinforce this feeling. Remember, you have to sell your patient on her next irrigation. The procedure itself may be quite simple, but it takes a great deal of skill and experience to inspire your patient's confidence in you and put her at ease. The angiolivage technique for irrigation of the maxillary sinuses is performed by the physician with the assistance of the technician. This irrigation technique is usually indicated for treatment of acute infection of the maxillary sinuses, either one or both of them, but only after more conservative treatment has not resolved the condition. After several days of treatment with antihistamines, decongestants, and antibiotics, the patient might still complain of acute sinusitis symptoms. Her upper teeth might hurt and there is usually tenderness in the cheek area. There may be some fever and possibly a purulent post-nasal drip. An x-ray would show some haziness of one or both maxillary sinuses. These sinuses are two air cavities located in the cheek area, one on each side. The maxillary sinuses are also called antra. The medial wall of the maxillary sinus, or antrum, is usually thin enough to puncture in order to make an artificial opening for irrigation. When the conservative treatment has failed, the physician might perform an antrilivage in order to drain out the bus. The first step in this procedure is to explain to the patient what the procedure is and how it will feel. You will be assisting the physician throughout the procedure. You too should talk to the patient and try to reassure her. Ensure that she should expect immediate relief when the procedure is done. Place towels or other draping to protect the patient's clothing. Give her the basin and explain that it will catch the fluids as they flow out of her mouth and nose. The doctor will have already explained that the procedure will be uncomfortable and messy, but not especially painful. You might reinforce this. Either you or the physician will administer a neocinephrine spray. This serves to shrink the mucous membranes, which opens the natural sinus passages and slows down the absorption of the anesthetic. 4% cocaine is an appropriate anesthetic. It is always administered by the physician, first as a spray, then on a cotton plunge let, applied to the area which will be punctured. The cocaine will require about 7 minutes to take full effect. Normally the effect will wear off after 45 minutes. There will be some variation in this. When the patient is anesthetized, the trocar needle is used to penetrate the membranes and bone and enter the sinus. The needle is inserted through the nostril and the puncture is made at this point beneath the inferior turbinate. The patient will usually have her eyes closed and should be well prepared for the sensation of puncture. When the needle is in place, the obturator or shaft is withdrawn. You must have the tubing ready to hand to the physician so that he may attach it. While the physician holds the needle in place, you must fill the syringe with solution from the solution tray and attach it to the tubing. The solution will usually be normal saline with 1 eighth percent neosinephrine. You may also be required to operate the syringe, gently forcing the solution into the sinus. The physician may wish to aspirate and collect the first material to be forced out of the sinus opening for later culture. You must be ready to give him the correct equipment. The solution will continue to be introduced into the sinus until the returning fluid is clear. The returning fluid flows out of the natural sinus opening and falls through the mouth and nose into the basin. When the irrigation is completed, the needle is removed. You will have the job of cleaning up the work area. You may have to collect some of the material in the basin for culture if it was not possible to collect such material earlier with the syringe. Either you or the physician must warn your patient not to blow her nose for a while. This would force material from the nasal cavity into the sinus, possibly causing reinfection. Your patient should feel immensely relieved both at completing the procedure and at the elimination of pressure and pain in her sinus. Your skill and dedication in accomplishing your own tasks and in assisting the physician are essential for the proper care of your patients and the smooth operation of the ENT clinic.