Ultrasound-Guided Pudendal Nerve Block for Intra and Postoperative Pain Management in Pediatric Penoscrotal Surgery

In this video, a bilateral ultrasound-guided pudendal nerve block is demonstrated on a 15-month-old healthy child undergoing circumcision and penoscrotal fusion repair. After the induction of general anesthesia, a nerve block time-out is conducted. Subsequently, the patient is positioned in the frog-leg stance by an assistant, and the perineum is cleaned using chlorhexidine. Using a high-frequency linear ultrasound probe, the ischiorectal fossa is identified between the ischial tuberosity and the anus at the 3 and 9 o’clock positions relative to the anus. A 22-gauge, 50-millimeter-long Pajunk needle is then inserted using an out-of-plane technique, advanced 1-2 cm deep and medial to the ischial tuberosity, until a subtle change in resistance or “pop” is felt, confirming the correct placement below the sacrospinous ligament. The local anesthetic (0.3 to 0.5 mL/kg of 0.2% Ropivacaine or 0.25% Bupivacaine on each side) is then incrementally injected, observed as spreading medially and beneath the ischial tuberosity. The block is then repeated on the other side. Our patient tolerated the procedure well and did not require any opioids intraoperatively, postoperatively in the post-anesthesia care unit, or at home following discharge.

Excision of Facial Venous Malformation

Introduction:

Facial venous malformations are challenging vascular anomalies that can significantly impact a patient’s quality of life. These malformations, characterized by abnormal clusters of dilated veins in the facial region, can cause significant cosmetic deformities, bleeding, and functional impairments. Surgical excision of facial venous malformations is a treatment option, aiming to address both the concerns and functional limitations associated with these vascular anomalies.

Case presentation:

The affected area on the lateral aspect of the upper eyelid margin was treated with a YAG laser set at 20 watts and one-second exposure time. This was followed by excision of a 1 x 2 cm segment of the affected skin above the eyelid margin. Using electrocautery, the skin, subcutaneous tissue, and venous malformation were dissected, avoiding branches of the facial nerve to the orbicularis oculi muscle. The incision was carried around the obvious margins of the malformation down to the temporalis muscle fascia. The dissection was performed underneath the lesion until it was completely resected. After excision of a portion of the eyebrow involved in the malformation, the deeper parts of the upper eyelid and orbicularis muscle affected by the venous malformation were removed. The deep portion of the dissection was not very vascular and was controlled with the bipolar and monopolar cautery. To achieve primary closure, we carefully undermined the forehead and facial skin. The lower facial skin flap was elevated and advanced, and primary closure was achieved with Vicryl sutures. Closure of the eyelid skin to the lateral forehead skin followed with chromic and Vicryl sutures to alleviate tension. Although the larger vascular lesion was excised from the skin and subcutaneous tissue, residual malformation remained around the upper eyelid and lateral orbital rim. This was dissected under the skin to remove the vessels and preserve the eyelid skin. Post-procedure, Mastisol and Steri-Strips were applied to the suture line to relieve tension and help wound healing.  The estimated blood loss was less than 30 mL. The patient had no complications and did well.

Conclusion:

In this case, the surgical intervention effectively removed most of the facial venous malformation. Despite some residual malformation, the procedure yielded satisfactory outcomes with no postoperative complications. The residual malformation in the upper eyelid can be controlled with a YAG laser and/or sclerotherapy.

Myringoplasty Using a Human Birth Tissue Allograft

This video demonstrates a myringoplasty procedure using Neox RT – a human birth tissue allograft – to repair a tympanic membrane perforation in a pediatric patient. We employ a “sandwich” technique, in which pieces of the allograft are placed both medial and lateral to the perforation. After partially filling the middle ear with dry, absorbable gelatin sponge, trimmed pieces of allograft are inserted sequentially in underlay and overlay fashion to remain medial and lateral to the perforation. Both the underlay and overlay pieces cover the perforation and overlap the native tympanic membrane around the perforation. More absorbable sponge is then inserted lateral to the graft to hold it in place against the tympanic membrane. Finally, antibiotic drops and bacitracin ointment are placed in the canal.

Eagle Syndrome (Calcification of the Stylohyoid Ligament) Excision

Abstract

Introduction: Eagle syndrome can affect many patients of any age, anywhere from 25 to 80 years old. The most common symptoms are ear and anterior superior neck pain underneath the angle of the jaw, tinnitus, some throat symptoms, and dizziness. There are two approaches that can be done for surgery, with our preference being for the intraoral approach.

The pathophysiology is that the stylohyoid ligament becomes calcified and can cause pressure on blood vessels and nerves, causing variable symptoms. It is frequently undiagnosed causing patients to visit several physicians before correctly identifying the problem.

A CT scan of the neck with or without contrast, can help identify the problem.

Case presentation: A 39-year-old female with a history of ear and upper neck pain at the angle of the jaw. CT imaging showed calcification of the stylohyoid ligament. Surgery was recommended and a trans-oral approach was used.

Methods: General anesthesia with muscle relaxation was used. A crow Davis or Dingman tractor was used to retract the endotracheal tube to allow exposure of the Oropharynx. Betadine was used to help sterilize the oropharynx. Palpation on each side is done to localize the calcified ligament and if present, the surgery is much easier to do. A 2.5 cm vertical incision is made in the anterior tonsillar pillar, being careful not to go too high on the soft palate because it can paralyze the soft palate causing significant reflux into the nasopharynx and nose, with speech and swallowing problems.

The tonsil capsule and the medial pterygoid muscle are identified, and the dissection is between the two. The calcified ligament is usually about 2.5 cm deep to that area. It is in or under the fat pad in the prevertebral area. It may be difficult to find, and it is helpful if your finger is passed through the incision to palpate deeper to feel the bony process.

The stylohyoid muscle and fat must be cleaned off the bone as high and low as can be dissected ideally using a combination of the monopolar and bipolar cautery. It is important to be careful in this area with the monopolar cautery because of the proximity to the internal carotid artery and jugular vein. Also, the vagus nerve can be injured.

A Kerrison rongeur is used to fracture the bone superiorly. The ligament is connected at the inferior part which can be divided with the cautery.

It is important to obtain good hemostasis using the bipolar cautery and saline irrigation. The wound is closed by sewing the tonsil capsule to the medial pterygoid muscle after which the mucosal incision is sewed. Preferably, vicryl sutures are used so that it will last approximately four weeks.

Bupivacaine 0.5% can be injected around the surgical site to decrease postop pain.

The surgery is done as an outpatient basis and the patient is given pain medication and antibiotics for significant throat pain lasting 7 to 10 days postop.

Conclusion: The removal of the calcified Stylohyoid ligament via an intraoral approach, can be simple or very complicated, and must be done carefully by an experienced surgeon to avoid major complications.

Most patients benefit significantly with relief of their symptoms and are very grateful. This case illustrates the surgical procedure that was easy to perform, but they are not all that easy.

Surgeons:

Siddharth Patel, MD

James Y Suen, MD

Conflicts of Interest: None

Funding: This research received no external funding

Department of Otolaryngology – Head and Neck Surgery, University of Arkansas for Medical Sciences, Little Rock, AR, USA

Arteriovenous Malformation (AVM) Resection

Abstract

Introduction: Arteriovenous malformations (AVMs) are abnormal connections between arteries and veins that lack an intervening capillary network. The high flow of arterial blood directly into veins can lead to the weakening of venous walls, potentially resulting in life-threatening hemorrhages.The primary treatment modalities for cerebral arteriovenous malformations (AVMs) include surgical resection, endovascular embolization.

Case presentation: A 34-year-old female presented with a roughly 7×7 cm arteriovenous malformation (AVM) located in the right temporoparietal area. The AVM extended both superficially and deeply into the infratemporal fossa and laterally towards the orbit. Imaging revealed the presence of multiple large contributing vessels in the preauricular area. The patient underwent embolization with interventional radiology one day prior to the surgical procedure.

Methods: Markings were made along the right upper hairline after trimming and continued down the preauricular skin. A #15 blade was utilized to make incisions through the epidermis and dermis, reaching the subcutaneous tissues. The temporoparietal and temporal flap fascia were dissected and carefully raised. Once the AVM was detached from the surrounding temporalis muscle and the zygomatic bone, its feeder vessels were ligated near the tragal pointer using hemoclips to aid in future localization. Hemostasis was successfully achieved with bipolar cautery. The temporalis muscle and its adjacent fascia were sutured closed with vicryl suture. Closure of the deep dermal layer was accomplished with 4-0 PDS, and the skin was closed in a running subcutaneous fashion using 5-0 monocryl.

Conclusion : We present a successful surgical resection of Arteriovenous Malformation with a prior embolization by interventional radiologist

Surgeons:

Coleman, Madison, MD,

Aryan D Shay ,MD

Gresham T Richter, MD, FACS

Conflicts of Interest: None

Funding: This research received no external funding

Department of Otolaryngology – Head and Neck Surgery, University of Arkansas for Medical Sciences, Little Rock, AR, USA
Arkansas Children’s Hospital, Little Rock, AR, USA

Excision of supratrochlear and supraorbital nerves

Abstract

Introduction: Frontal  headache is a common, costly and debilitating disease process.When treatments, including medication management and physical therapy, prove ineffective, surgical interventions become a viable consideration  Among these interventions, the excision of supratrochlear and supraorbital nerves stands out as a potential therapeutic option.

Case presentation: 24-year-old female with history of chronic frontal headaches who presents for resection of supraorbital and supratrochlear nerves.

Methods: A 4 cm incision was carefully made along the right eyebrow. This incision extended through the subcutaneous tissue. Employing a combination of blunt and sharp dissection techniques, we successfully identified supratrochlear nerves, observing multiple branches emerging from the orbit. All branches were excised via scissors . Subsequently, we located the supraorbital nerve exiting through a foramen, just above the mid-orbital rim, and proceeded to excise it. The wound was thoroughly irrigated with normal saline to ensure cleanliness, and hemostasis was  maintained throughout the procedure using both monopolar and bipolar cautery. Closure of the incision was executed in a layered fashion, employing 3-0 Monocryl and 5-0 Chromic sutures. To minimize postoperative discomfort, 0.5% Marcaine with epinephrine was injected into the nerve areas.

Conclusion :The excision of the supraorbital and supratrochlear nerves offers a promising option for managing chronic frontal headaches when conventional treatments prove ineffective. This case report underscores the successful outcome of this procedure in a 24-year-old female who had been enduring debilitating headaches.

Surgeons:

Dang-Khoa Nguyen, MD

James Y Suen,MD

Conflicts of Interest: None

Funding: This research received no external funding

Department of Otolaryngology – Head and Neck Surgery, University of Arkansas for Medical Sciences, Little Rock, AR, USA

Excision of greater occipital nerves and 3rd occipital nerves

Abstract

Introduction: Occipital headache is a common, costly and debilitating disease process.When traditional therapies such as medication management and physical therapy fail to provide relief, surgical interventions may be considered. This procedure involves the excision of the 3rd and  both greater occipital nerves. 

Case presentation: 36 years old. female with history of chronic refractory occipital headaches  involving both greater occipital nerves and 3rd occipital nerves who presented for resection of those nerves.

Methods: A 10cm incision was marked on the posterior neck, positioned inferior to the occipital  skull base. Subsequently, the incision was carefully extended through the subcutaneous tissue. By means of both blunt and sharp dissection through the posterior muscle fascia where it inserts into the skull base, the right greater occipital nerve was identified and dissected into the paravertebral muscles and several centimeter of the nerve was resected so it could not grow back together. A corresponding procedure was employed for the left greater occipital nerve, located approximately 3 cm from the midline, and excised using the same technique. Additionally, the third occipital nerves situated in the midline were excised to address the entirety of the issue. Following these procedures, the wound was thoroughly irrigated with normal saline to ensure cleanliness, and hemostasis was diligently maintained throughout the surgical intervention using both monopolar and bipolar cautery. To alleviate postoperative discomfort, 0.5% Marcaine with epinephrine was carefully injected into the nerve areas.

The fascia needs to be closed with  strong sutures and  the skin and subcutaneous tissue were closed  in two layers. 

Conclusion :The excision of  greater occipital nerves presents a viable option for the management of chronic occipital headaches when conservative treatments prove ineffective. This case report highlights the successful outcome of such a procedure in a 36-year-old female suffering from debilitating headaches

Surgeons:

Dang-Khoa Nguyen, MD

James Y Suen,MD

Conflicts of Interest: None

Funding: This research received no external funding

Department of Otolaryngology – Head and Neck Surgery, University of Arkansas for Medical Sciences, Little Rock, AR, USA

Thyroid Cyst Removal with Hemithyroidectomy

This video shows a thyroid cyst removal that resulted in a hemithyroidectomy. The patient is placed under general anesthesia and intubated using a mac video laryngoscope and an EMG endotracheal tube. The ET tube has 4 stainless steel wire electrodes which touch the vocal cords for monitoring during surgery. After video intubation electrode placement is verified by direct stimulation of the area.

The surgeon makes a curvilinear skin crease incision in the front of the neck, to minimize the visibility of a scar. Afterwards, subplatysmal flaps are elevated and the midline raphe is dissected exposing the sternohyoid muscle, which is retracted laterally, and the sternothyroid muscle that is dissected off the left thyroid gland.

The thyroid cyst is found superficial and dissected, keeping in mind that anything suspicious for the recurrent laryngeal nerve is stimulated prior to dissection. The cyst is ruptured and sent for frozen pathology. The results returned as thyroid, so the surgeon proceeded with a hemithyroidectomy. The superior and inferior parathyroids were identified and dissected free. Hemostasis was achieved with electrocautery and confirmed with Valsalva. Strap musculature platysma and skin are closed. And lastly, mastisol and steri-strips are placed perpendicular to the wound.

Pediatric Lumbar Epidural Catheter Placement via the Landmark Technique.

This video demonstrates an epidural catheter placement on a 2-year-old, 12kg male patient presenting for left hip osteotomy. His past medical history was remarkable for congenital heart defects, bilateral congenital hip dislocations, and a sacral dimple which is sometimes associated with neurologic spinal canal abnormalities. In this case, no neurologic anatomical abnormalities were demonstrated on the neonatal spine ultrasound. The patient was placed in a left lateral decubitus position. Using anatomical landmarks like Tuffier’s line or the intercristal line corresponding to L4-L5 level, the target level for needle placement was identified and marked. The patient’s skin was sterilized and draped under sterile conditions. An 18-gauge, 5 cm length Tuohy needle was used to encounter the epidural space. A general guideline for the depth to the epidural space from the skin is approximately 1mm/kg of body weight¹. Subsequently, a 20-gauge catheter was placed through the needle to a depth of 4.5 cm at the level of the skin. Negative aspiration of blood or CSF was confirmed. A test dose was calculated at 0.5 mcg/kg epinephrine or 0.1ml/kg of lidocaine 1.5% with epinephrine 1:200,000. In this case, a 1.2 mL test dose of lidocaine 1.5% with epinephrine 1:200,000 was given without any observed cardiovascular changes (e.g. ≥ 25% increase or decrease in T wave amplitude, HR increase ≥ 10 bpm, or SBP increase ≥ 15 mmHg)¹. Finally, the catheter was secured to the back of the patient. Parental consent was obtained for the publication of this video.

Branchial Cleft Cyst Excision

Branchial cleft cysts are a benign anomaly caused by incomplete obliteration of a primordial branchial cleft.  They typically appear in childhood or adolescence, but can appear at any age. They present as a non-tender, fluctuant mass following an upper respiratory infection, most commonly at the anterior border of the sternocleidomastoid muscle. These lesions are thought to originate during the 4th week of gestation when the branchial arches fail to fuse. The second branchial cleft is the most common site (95%) and cysts from in this distribution can affect cranial nerves VII, IX, and XII. 

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