Microdebrider Assisted Lingual Tonsillectomy

Microdebrider Assisted Lingual Tonsillectomy

Adrian Williamson, Michael Kubala MD, Adam Johnson MD PhD, Megan Gaffey MD, and Gresham Richter MD

The lingual tonsils are a collection of lymphoid tissue found on the base of the tongue. The lingual tonsils along with the adenoid, tubal tonsils, palatine tonsils make up Waldeyer’s tonsillar ring. Hypertrophy of the lingual tonsils contributes to obstructive sleep apnea and lingual tonsillectomy can alleviate this intermittent airway obstruction.1,2 Lingual tonsil hypertrophy can manifest more rarely with chronic infection or dysphagia. A lingual tonsil grading system has been purposed by Friedman et al 2015, which rates lingual tonsils between grade 0 and grade 4. Friedman et al define grade 0 as absent lingual tonsils and grade 4 lingual tonsils as lymphoid tissue covering the entire base of tongue and rising above the tip of the epiglottis in thickness.3

Lingual tonsillectomy has been approached by a variety of different surgical techniques including electrocautery, CO2 laser, cold ablation (coblation) and microdebridement.4-9 Transoral robotic surgery (TORS) has also been used to improve exposure of the tongue base to perform lingual tonsillectomy.10-13 At this time, there is not enough evidence to support that one of these techniques is superior.

Here, we describe the microdebrider assisted lingual tonsillectomy in an 8 year-old female with Down Syndrome. This patient was following in Arkansas Children’s Sleep Disorders Center and found to have persistent moderate obstructive sleep apnea despite previous adenoidectomy and palatine tonsillectomy. Unfortunately, she did not tolerate her continuous positive airway pressure (CPAP) device. The patient underwent polysomnography 2 months preoperatively which revealed an oxygen saturation nadir of 90%, an apnea-hypopnea index of 7.7, and an arousal index of 16.9. There was no evidence of central sleep apnea. The patient was referred to otolaryngology to evaluate for possible surgical management.

Given the severity of the patient’s symptoms and clinical appearance, a drug induced sleep state endoscopy with possible surgical intervention was planned. The drug induced sleep state endoscopy revealed grade IV lingual tonsil hypertrophy causing obstruction of the airway with collapse of the epiglottis to the posterior pharyngeal wall. A jaw thrust was found to relieve this displacement and airway obstruction. The turbinates and pharyngeal tonsils were not causing significant obstruction of the airway. At this time the decision was made to proceed with microdebrider assisted lingual tonsillectomy.

First, microlaryngoscopy and bronchoscopy were performed followed by orotracheal intubation using a Phillips 1 blade and a 0 degree Hopkins rod. Surgical exposure was achieved using suspension laryngoscopy with the Lindholm laryngoscope and the 0 degree Hopkins rod. 1% lidocaine with epinephrine is injected into the base of tongue for hemostatic control using a laryngeal needle under the guidance of the 0 degree Hopkins rod. 1.     The 4 mm Tricut Sinus Microdebrider blade was set to 5000 RPM and inserted between the laryngoscope and the lips to resect the lingual tonsils. Oxymetazoline-soaked pledgets were used periodically during resection to maintain hemostasis and proper visualization. A subtotal lingual tonsillectomy was completed with preservation of the fascia overlying the musculature at the base of tongue.

She was extubated following surgery and there were no postoperative complications. Four months after postoperatively the patient followed up at Arkansas Children’s Sleep Disorders Center and was found to have notable clinical improvement especially with her daytime symptoms. A postoperative polysomnography was not performed given the patient’s clinical improvement.

Endoscopic Posterior Cricoid Split with Rib Grafting for Posterior Glottic Stenosis

Endoscopic posterior cricoid split with rib grafting can be used in children with Bilateral Vocal Fold Immobility due to bilateral vocal fold paralysis or cricoarytenoid joint fixation with posterior glottic stenosis. It is preferred to open laryngotracheal reconstruction because it does not disrupt the anteior cricoid ring therby preserving the “spring” of the cricoid.

DOI#: http://dx.doi.org/10.17797/5w4hsqmgnq

Endoscopic Posterior Cricoid Split with Rib Grafting for Bilateral Vocal Fold Paralysis

Endoscopic posterior cricoid split with rib grafting can be used in children with bilateral vocal fold immobility due to bilateral vocal fold paralysis or cricoarytenoid joint fixation with posterior glottic stenosis. It is preferred to vocal cordotomy/arytenoidectomy because it is a non-destructive procedure with no impact on voice and swallowing.  It is also preferred to open laryngotracheal reconstruction because it does not disrupt the anterior cricoid ring thereby preserving the “spring” of the cricoid.

DOI: http://dx.doi.org/10.17797/gcnyoduseo

Endoscopic Anterior Cricoid Split with Balloon Dilation for Failed Extubation

This is done in infants who have had failed extubation and had maximal medical treatment(steroids,epinephrine etc). This procedure done with careful patient selection will help avoid tracheostomy. The Larynx is suspended using a Lindholm Laryngoscope with patient spontaneously breathing with ventilating through the side port. The airway is first completely assessed to make sure there is no other lesion to explain the failure. The larynx is then suspended with a laryngoscope(Lindholm). With direct visualization a micro laryngeal sickle knife is used to divide the anterior cricoid with palpation of the neck from outside to feel the cut being made. Care is taken not to injure the anterior commissure. Once this is achieved a 5-7 mm balloon is used in an infant to dilate the sub glottis for 30-60 seconds. The patient is either extubated on the table or in a day.Further 24 hrs of steroids is given.

For further reading: Laryngoscope. 2012 Jan;122(1):216-9. http://dx.doi.org/10.1002/lary.22155. Epub 2011 Nov 17. Endoscopic anterior cricoid split with balloon dilation in infants with failed extubation. Horn DL, Maguire RC, Simons JP, Mehta DK.

DOI: http://dx.doi.org/10.17797/1y99qiqe93

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