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.
School: UAMS Medical Center (University of Arkansas for Medical Sciences)
Ultrasound-Guided Rectus Sheath Block for Intraoperative and Postoperative Pain Management in Pediatric Patients
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.
Pediatric Ultrasound-Guided Caudal Block
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.
Right Neck Dissection
Introduction
Neck dissection stands as a crucial surgical procedure predominantly utilized in addressing head and neck cancers. It involves the methodical elimination of lymph nodes and potentially adjacent tissues to curb cancer dissemination. This procedure can be delineated into several types based on the extent of surgery and the structures targeted, including radical neck dissection (RND), modified radical neck dissection (MRND), selective neck dissection (SND), and extended neck dissection.[1]
Neck dissection is recommended for various conditions such as metastatic neck cancer, cancers affecting the oral cavity, pharynx, larynx, or thyroid with a high risk of lymphatic spread, and as a prophylactic measure in cases of head and neck cancers with a high risk of occult metastasis.[1] Understanding the anatomy of the cervical lymphatic system, which is divided into distinct levels (I-VII) each containing specific groups of lymph nodes, is essential for conducting effective neck dissection.[2,3] The radical neck dissection (RND), introduced by George Crile Sr. in 1906, was long regarded as the standard treatment for metastatic neck disease.[2,4] However, modifications to the procedure have been developed over time to reduce associated morbidity while ensuring oncological safety.[1]
Surgical procedure
The surgical procedure of neck dissection typically involves a series of steps: an incision is made along an existing neck crease, subplatysmal flaps are then elevated to expose underlying anatomical structures and lymph nodes, different groups of lymph nodes are systematically removed depending on the type of dissection, and finally, the surgical site is closed in layers with the placement of a drain.[4] Complications of neck dissection may include nerve damage resulting in shoulder dysfunction, bleeding and hematoma formation, infection and issues with wound healing, as well as the development of lymphedema.[1]
Conclusion
Neck dissection is a vital procedure in the management of head and neck cancers, designed to remove lymph nodes that may harbor metastatic disease. The type of neck dissection performed is tailored to the extent of disease and the need to preserve function and reduce morbidity. A thorough understanding of the anatomy and careful surgical technique are essential to optimize outcomes and minimize complications.
References
Harish K. Neck dissections: radical to conservative. World J Surg Oncol. 2005 Apr 18;3(1):21. doi: 10.1186/1477-7819-3-21. PMID: 15836786; PMCID: PMC1097761.
Jiang, Z., Wu, C., Hu, S. et al. Research on neck dissection for oral squamous-cell carcinoma: a bibliometric analysis. Int J Oral Sci 13, 13 (2021). https://doi.org/10.1038/s41368-021-00117-5
Rigual NR, Wiseman SM. Neck dissection: current concepts and future directions. Surg Oncol Clin N Am. 2004;13(1):151-166. doi:10.1016/S1055-3207(03)00119-4
Antonio Riera March, M. (2023, November 28). Radical neck dissection. Background, History of the Procedure, Problem. https://emedicine.medscape.com/article/849895-overview?form=fpf
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