Medial Orbital Dermoid Cyst Removal

Dermoid cysts are the most common orbital tumor in childhood. It is a developmental benign choristoma, arising from ectodermal sequestration along the lines of embryonic fusion of mesodermal processes. It is lined by keratinized stratified squamous epithelium and expands slowly due to constant desquamation and dermal glandular elements. They are usually smooth, painless, mobile, or partially mobile lesions mostly present at the fronto-zygomatic suture with proptosis, displacement, ptosis, or diplopia, depending on depth and extent1. 

Although lateral orbital dermoid cysts are common, medial orbital dermoid cysts are rare2. Our patient had a right medial orbital congenital dermoid cyst since birth. At the presentation, the patient was 2 years old. On CT, the cyst measured 5 mm at the upper lid/medial canthus of the right orbit with subtle bone remodeling. He had a mildly clogged tear duct on the left but was otherwise asymptomatic. The decision was made to surgically remove the dermoid cyst. 

In this video, we present a case of removal of a medial orbital dermoid cyst in a 2-year-old patient. 
An incision was planned directly over the lesion. It was marked following the natural skin tension lines of the face to give the most natural esthetic appearance.
A small amount of Local anesthetic (0.5 ml of Lidocaine and Epinephrine) was injected under the skin to promote hemostasis and postoperative pain control.
A continuous Incision was made with a #15 blade on the skin.
Westcott scissors were used to dissect further through the subcutaneous tissue to expose the cyst and slowly dissect it from the normal tissue surrounding it.
Extra care was made to protect the integrity and avoid the rupture of the cyst.
After the entire cyst was freed from the surrounding tissue,  it was carefully removed from its attachments to the periosteum using Westcott scissors.
The incision was closed in a two-layer fashion.
The deeper layer was closed by 6.0 Vicryl in a vertical mattress fashion with 2 interrupted sutures.
Next, wound edge eversion was achieved by placing two interrupted, superficial 5.0 fast-absorbing gut sutures. This will minimize the scar appearance.
Dermabond was applied next and the sutures were protected by a small piece of Tegaderm. This will be left in place until it spontaneously falls off.

Costochondral Graft Harvest for Laryngoplasty

Rib cartilage is the workhorse autogenic material for laryngeal airway expansion surgery.  Most usually one will use the right-sided 5th or 6th rib as the donor site.  A 2.5 cm incision is made directly over the rib, in the inframammary crease from the lateral aspect of the nipple to the sternal xyphoid process.  Subcutaneous fat is removed.  The overlying intercostal muscles are dissected up away from the rib, divided, and retracted– effectively exposing the rib.  Perichondrium is sharply incised on the superior and inferior borders of the rib.  A posterior tunnel is elevated in asub-perichondrial plane using blunt instruments, just medial to the osseocartilagenous (OC) junction.  A Doyen elevator is inserted into the tunnel and the rib is transected right at the OC junction.  The rib is then elevated from lateral to medial in the subperichondrial plane.

Such a manuever ensures that the plueral space will not be entered, protecting the pleural membrane from injury.

Once the rib has been elevated to the sternal attachment, it is completely released.  The pleura is inspected directly to confirm it has not been injured.  The wound is filled with normal saline and 30 cm of water pressure valsalva is applied by the anesthesiologist for 30 seconds, to ensure no air is escaping the lung.  The wound is closed in layers over a rubber band drain placed in a dependent position.

One should be able to harvest 2.5-3 cm of cartilage. Post-operatively a chest radiograph is obtained to rule out pneumothorax

DOI: http://dx.doi.org/10.17797/2jra6vjlud

Submental Intubation

Presented is a case of submental intubation performed prior to maxillomandibular advancement for the treatment of obstructive sleep apnea. Submental intubation is a viable alternative to tracheostomy for cases in which nasal intubation is contraindicated (e.g. trauma), or uninterrupted access to the oral cavity is preferred. [1] Briefly, the technique consists of performing oral intubation, and then exteriorizing the endotracheal tube through a tract created from the floor of mouth to the submental triangle. At the end of the case, the tube can be passed into the oral cavity, returning to an oral intubation.

Surgeon: Raj C. Dedhia, MD, MSCR, Department of Otolaryngology, Emory University School of Medicine

Video Production: Clara Lee, MS4, Emory University School of Medicine

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