Introduction: Cartilage tympanoplasty is a surgical procedure aimed at repairing the tympanic membrane using cartilage grafts. This technique is particularly effective in cases of chronic otitis media, recurrent perforations, where traditional methods may fail. The procedure not only aims to close the perforation but also to restore hearing and reconstruct a healthy middle ear cavity. This case report presents a patient undergoing cartilage tympanoplasty placement procedure, highlighting the surgical technique. Procedure Presentation: The cartilage tympanoplasty procedure begins with harvesting tragal cartilage, carefully preserving an anterior remnant for cosmetic purposes. The graft is measured, harvested, and trimmed to fit the tympanic membrane defect, with the perichondrium preserved on one side. A central trough is carved for seating on the malleus handle. The tympanomeatal flap is elevated, allowing placement of the graft in the middle ear cavity medial to the tympanic membrane. Crushed gel foam supports the graft, and the tympanomeatal flap is draped over it. The surgeon carefully inspects to ensure proper placement and complete perforation coverage. Additional gel foam in the canal prevents graft lateralization, completing this precise and meticulous surgical technique. Conclusion :  This case report demonstrates the effectiveness of cartilage tympanoplasty in treating chronic otitis media with tympanic membrane perforation. The use of cartilage grafts provides a robust and reliable method for tympanic membrane reconstruction, offering excellent anatomical and audiological outcomes. Further studies with larger patient cohorts are recommended to validate these findings and refine the surgical technique.

Simultaneous Translabyrinthine Vestibular Schwannoma removal and Cochlear implantation in small tumor using CI632 device

Introduction: Cartilage tympanoplasty is a surgical procedure aimed at repairing the tympanic membrane using cartilage grafts. This technique is particularly effective in cases of chronic otitis media, recurrent perforations, where traditional methods may fail. The procedure not only aims to close the perforation but also to restore hearing and reconstruct a healthy middle ear cavity. This case report presents a patient undergoing cartilage tympanoplasty placement procedure, highlighting the surgical technique. Procedure Presentation: The cartilage tympanoplasty procedure begins with harvesting tragal cartilage, carefully preserving an anterior remnant for cosmetic purposes. The graft is measured, harvested, and trimmed to fit the tympanic membrane defect, with the perichondrium preserved on one side. A central trough is carved for seating on the malleus handle. The tympanomeatal flap is elevated, allowing placement of the graft in the middle ear cavity medial to the tympanic membrane. Crushed gel foam supports the graft, and the tympanomeatal flap is draped over it. The surgeon carefully inspects to ensure proper placement and complete perforation coverage. Additional gel foam in the canal prevents graft lateralization, completing this precise and meticulous surgical technique. Conclusion :  This case report demonstrates the effectiveness of cartilage tympanoplasty in treating chronic otitis media with tympanic membrane perforation. The use of cartilage grafts provides a robust and reliable method for tympanic membrane reconstruction, offering excellent anatomical and audiological outcomes. Further studies with larger patient cohorts are recommended to validate these findings and refine the surgical technique.

This video demonstrates how to perform an ultrasound-guided intermediate cervical plexus nerve block for postoperative pain control in a pediatric patient presenting for cochlear device implant.

In this video, a bilateral ultrasound-guided rectus sheath nerve block is demonstrated on a 7-year-old male child undergoing umbilical hernia repair. After the induction of general anesthesia, nerve block time-out is conducted. Following this, the periumbilical area is cleansed using chlorhexidine. A high-frequency linear ultrasound probe is then placed in a transverse orientation lateral to the umbilicus to identify the rectus muscle and its posterior rectus sheath. The three lateral abdominal wall muscles—internal oblique, external oblique, and transversus abdominis—are also visualized lateral to the rectus muscle. Using an in-plane technique, a 22-gauge, 50-millimeter-long Pajunk needle is inserted from lateral to medial direction. The needle is advanced through the subcutaneous tissue and the body of the rectus muscle until it reaches the target plane between the rectus muscle and the posterior rectus sheath. Correct needle placement is confirmed through hydro dissection with normal saline, where proper spread is indicated by separation of the rectus sheath from the muscle or by the rectus muscle lifting up. Next, 0.2% Ropivacaine, a local anesthetic, is incrementally injected. The procedure is then repeated on the opposite side with total drug volume typically ranging from 0.05 ml/kg to 1.0 ml/kg up to a maximum total volume of 10 to 20 ml. The patient tolerates the procedure well and does not require any opioids intraoperatively or postoperatively in the post-anesthesia care unit.

Educational/Technical Point(s): Endoscopic butterfly inlay tympanoplasty is a reliable and useful technique in select pediatric patients. This technique prevents the need for flap elevation, intratympanic myringosclerosis excision that could result in significantly larger perforation, or malleus dissection which can result in permanent hearing reduction. The procedure has a shorter operative time than traditional techniques and excellent results in pediatric patients. Introduction: Butterfly inlay tympanoplasty is a more recently described but validated technique for repairing select tympanic membrane perforations.¹ Following its validation in adult patients, small series have demonstrated its successful use in the pediatric population as well, including via endoscopic approach. ² Despite these findings, the indications for when to use this repair technique remain nebulous. We discuss our institution’s approach to the use of this technique and factors that influence its implementation through a case presentation. Case Presentation: We present a 14-year-old female with a history of long standing anterior tympanic membrane perforation. She was seen in consultation at our quaternary children’s hospital with a remote history of ear tube placement, subsequent extrusion, and ongoing perforation. Audiometry revealed a moderate conductive hearing loss and large volume type B tympanogram. Examination demonstrated an ~30% anterior central clean dry perforation. Her perforation was anterior to the handle of the malleus and demonstrated a significant intratympanic myringosclerotic plaque adjacent to the perforation. Given the location, and adjacent plaque whose removal would have resulted in nearly the double the size of the perforation, endoscopic butterfly inlay technique was recommended. Technique: The patient was brought to the operating room and injected and prepped in standard fashion including injection of local anesthesia to the donor tragal site. The perforation was rimmed using a Rosen needle and the subsequent tissue removed with cup forceps. Following recipient site preparation, the perforation was measured using a standard right angle hook whose length is 3 mm demonstrating a 4 mm by 3 mm perforation. Attention was turned to harvesting a tragal graft in standard fashion. Using a 5 mm dermal punch, a full thickness portion of the cartilage was obtained ex vivo and the residual cartilage was replaced into the donor site for any future needs and the wound closed in simple interrupted fashion. The cartilage was scored circumferentially with a 15 blade creating locking flanges for the graft. The graft was then placed via alligator. The graft was purposefully placed through the perforation into the middle ear cleft, and then retracted by its perichondrium into the perforation, essentially “locking” it into place. Additional flange adjustments were made using a Rosen needle to ensure the graft was seated, appropriately. The tympanic membrane was coated with bacitracin and the patient was awoken from anesthesia. Standard post operative tympanoplasty care was recommended including dry ear precautions and avoidance of heavy physically exercise until her post operative follow up. At follow up, she demonstrated 100% graft take and resolution of her prior hearing loss with a mobile tympanic membrane. Conclusion: Endoscopic butterfly inlay tympanoplasty is a reliable and useful technique in select pediatric patients. This technique prevents the need for flap elevation, intratympanic myringosclerosis excision that could result in significantly larger perforation, or malleus dissection which can result in permanent hearing reduction. The procedure has a shorter operative time than traditional techniques and excellent results in pediatric patients.

This video demonstrates how to perform an ultrasound-guided single-shot caudal block for postoperative pain control in a pediatric patient about to undergo bilateral inguinal hernia repair.

This video depicts the surgical excision of a pyogenic granuloma on the lower eyelid. The patient was brought into the operating room and general anesthesia was induced, the base of the lesion was injected with lidocaine and epinephrine. A warm compress was applied to soften the crusted lesion. The crust was then gently elevated revealing the giant pyogenic granuloma. A chalazion curette was used to completely remove the lesion. A chalazion clamp was utilized to stabilize the lid and for hemostasis purposes.

This video provides an elucidation of the surgical steps involved in performing an endoscopic perctaneous suture laterlization in a neonate with bilateral vocal fold paralysis.

Four Gland Duct Ligation with Botulinum Injections  Background:   This video visualizes the four-duct ligation surgery for chronic sialorrhea. Sialorrhea is characterized by the improper spilling of saliva, most commonly due to poor muscle coordination1. Controlling oral secretions with the perioral muscles and the act of swallowing takes precise contraction from voluntary and reflex contractions. Sialorrhea is common in newborns and children up to 5 since they have not learned to coordinate these contractions yet1. The most common etiology of persistent, or new, sialorrhea is cerebral palsy, amyotrophic lateral sclerosis, seizures, cerebrovascular accidents, facial paralysis, and dental problems1.While many neurological conditions can predispose a child to sialorrhea, cerebral palsy is most common, comprising up to 10% of cases3.The side effects of untreated sialorrhea include increased risk of infections, dental caries, and interference with speech. Aspiration pneumonia is a serious consequence from pooling of saliva in the posterior pharynx3. Patients can also become malnourished due to trouble chewing, loss of fluids/electrolytes, and loss of protein2. Non-evasive measures such as oral motor therapy, behavior modification therapy via biofeedback, and drug therapy should be considered before proceeding to surgical treatment2. Surgical treatment is preferred when the patient is at risk for aspiration pneumonia3. One of the most common surgical procedures for sialorrhea is the four-gland duct ligation. While the four-gland duct ligation is low risk for complications, facial swelling, aspiration pneumonia, oxygen desaturation, and vomiting are potential complications. Out of these, facial swelling was the most common adverse event3.  Methods:   An appropriate surgical candidate was identified in the clinic and advised about the risks and benefits of the procedure. The patient was appropriately prepped and inducted under general anesthesia. An oral side bitter was placed to visualize the oral cavity. Stensen's duct was identified on the left with army navy retraction. A lacrimal probe was used to maintain the duct opening and an alice retractor was used to hold the duct in place. The dissection was performed bluntly and with cautery. Care was taken to prevent injury to the duct and to provide clear exposure. The probe was removed, and the proximal portion of the duct was ligated with two oppositely placed 3.0 silk sutures. The mucosa was then closed with 4.0 chromic suture in a simple interrupted stitch. The same procedure was performed on the contralateral side. The focus was then turned to whartons duct. The oral side bitter was removed, and the tongue was retracted using an army navy. The right papilla was identified and retracted with a Geralds with teeth to maintain proper visualization of the duct. Blunt and cautery dissection was performed around the duct for proper exposure. Once down to the base of the duct, tonsil clamps were used to clamp just proximal to the gland to aid with suture ligation. Two oppositely placed 3.0 silk sutures were used to ligate the duct. The mucosa was closed with a 4.0 chromic stitch. The exact same procedure was performed on the left whartons duct. Once complete the oral cavity was irrigated and cleaned. Ultrasound was then brought into the field. Under direct visual guidance 1mg/kg of botulinum toxin was injected into the parotid and submandibular glands using the hockey shaped ultrasound probe. Having tolerated the procedure well, the patient was turned back over to anesthesia, awakened and transferred to the recovery room in stable condition.   Results:   There were no complications encountered before, during, or after the procedure. The patient was followed in clinic for 1 year and the patient's care giver reported satisfactory reduction in sialorrhea.   Discussion:   This video shows the steps of performing a 4-gland duct ligation with botulinum toxin injections. It is a commonly indicated procedure in children under 5 years of age for chronic sialorrhea refractory to other treatment options. While not first line therapy, this procedure should be heavily considered for due to post-operative success and care giver satisfaction.               References:   Jean-Paul Meningaud, Poramate Pitak-Arnnop, Luc Chikhani, Jacques-Charles Bertrand, Drooling of saliva: A review of the etiology and management options, Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontology, Volume 101, Issue 1,2006, Pages 48-57, ISSN 1079-2104  Little, S.A., Kubba, H. and Hussain, S.S.M. (2009), An evidence-based approach to the child who drools saliva. Clinical Otolaryngology, 34: 236-239. https://doi-org.libproxy.uams.edu/10.1111/j.1749-4486.2009.01917.x  Khan WU, Islam A, Fu A, et al. Four-Duct Ligation for the Treatment of Sialorrhea in Children. JAMA Otolaryngol Head Neck Surg. 2016;142(3):278–283. doi:10.1001/jamaoto.2015.3592