Intracapsular tonsillectomy (tonsillotomy) offers significant advantages over the extracapsular approach. By preserving residual tonsillar tissue and the capsule as a biological dressing, it protects the underlying musculature with its vessels and nerves, while delivering equivalent clinical outcomes with reduced complications of postoperative pain, dehydration, and bleeding. There is no standardized approach in performance of a tonsillotomy , unlike the extracapsular approach. Additionally, when performing a tonsillotomy on large hypertrophied tonsils, visualizing the posterior pillar—often hidden behind tonsillar tissue—can be challenging, potentially putting this muscular structure at risk for damage and negating the advantages of a tonsillotomy. We describe a standardized technique for tonsillotomy using a midline split within the tonsillar tissue, creating a “coffee bean” appearance that serves as a pivot point for retraction. This approach allows for more accurate distinction between the posterior tonsil and the pillar, resulting in more precise ablation.
School: Weill Cornell Medical College
Submucous Cleft Palate Repair: Furlow Double-Opposing Z-Palatoplasty
32-month-old male with Coffin Siris syndrome, bilateral middle ear effusions, and velopharyngeal insufficiency who presents with a submucous cleft palate.
Supraglottoplasty for Laryngomalacia (Cold Steel)
1. Purpose of Surgery: To alleviate upper airway obstruction secondary to laryngomalacia after failed medical management (twice daily proton pump inhbitor, reflux precautions). Indications for surgery are the following: failure to thrive, dysphagia, aspiration, cyanosis, sleep apnea, pulmonary hypertension, core pulmonale, pectus excavatum. Approximately 10% of children with laryngomalacia will meet criteria for surgery. 2. Instruments: Parson’s laryngoscope, Medtronic MicroFrance Bouchayer Laryngeal instruments (heart shaped forceps, fine cup forceps, Micro Scissors curved right &left, micro suction), oxymetazoline soaked pledgelet 3. Landmarks: vallecula, epiglottis, aryepiglottic fold, cuneiform cartilage, interarytenoid space 4. Procedure: a. Larynx sprayed with topical 2% lidocaine. and a direct laryngoscopy and bronchoscopy is performed to rule out a synchronous airway lesions. b. Parson’s laryngoscope placed in the vallecula and in suspension with the patient spontaneously breathing. Inhalational anesthesia is given through sideport of laryngoscope. c. If the aryepiglottic fold is shortened then it is divided with a curved micro scissor at its attachment to the epiglottis. Division proceeds until the epiglottis is released and it springs anteriorly. (Special care should be taken to not divide the pharyngoepiglottic fold). d. If the cuneiforms cartilage is prolapsing into the airway then it is grasped with a small cup forcep or heart shaped forcep and removed with a curved scissor making sure not to remove mucosa/tissue in the interarytenoid region. e. Hemostasis is achieved with an oxymetazoline soaked pledge let. f. Steps c, d, and e are repeated on the contralateral side. g. Patient remains extubated and transferred to the intensive care unit. Decadron 0.5mg/kg every 8 hours for 24 hours. Twice daily proton pump inhibitor and reflux precautions for at least 30 days and then weaned off. h. Clinical swallow evaluation is performed 4 hours postoperatively and patient resumes age appropriate diet. i. Flexible fiberoptic laryngoscopy is performed one week postoperatively. 5. Conflict of interest: none 6. References: none
DOI#: http://dx.doi.org/10.17797/cb0bwa6ggv
Endoscopic Repair of Type 1 Posterior Laryngeal Cleft
1. Purpose of the Procedure: To repair a type 1 posterior laryngeal cleft that is resulting in feeding difficulty and aspiration which fails medical management.
2. Instruments: Parsons Laryngoscope, Lindholm vocal fold spreader (Karl Storz 8654B), Double armed 5.0 Vicryl 45 cm dyed suture on a tapered needle, Omniguide carbon dioxide laser (5 watts, pulsed mode), Microlaryngoscopy right sided curved alligator, Knot pusher
3. Landmarks: The false vocal folds should be separated with a Lindholm vocal fold spreader allowing for good visualization of the interarytenoid region.
4. Procedure:
a. Parson’s laryngoscope placed in the vallecula and in suspension with spontaneous ventilation
b. Lindholm vocal fold spreader inserted exposing the interarytenoid region.
c. Interarytenoid region is demucosalized in a diamond shape with a carbon dioxide laser (5 watts, pulsed mode). The char is wiped clean with a pledglet.
d. A double armed needle with a dyed 5.0 tapered Vicryl suture should be loaded on to a right sided microlaryngoscopic curved alligator in “fishhook” fashion. One arm is pushed through the right side and one arm is pushed through the left side of the corners of the demucosalized region. This will ensure that the knot sits posteriorly. (A dyed suture will also allow for easy visualization of the suture postoperatively in the office)
e. Clinical swallow evaluation on postoperative day #1. Postoperative follow up and swallow study on Day #7. Additional follow up on postoperative day #30
5. Conflict of Interest: none
6. No references
DOI: http://dx.doi.org/10.17797/f0jsgqdoup
Revision Supraglottoplasty
1. Purpose of Surgery: To alleviate upper airway obstruction secondary to recurrent laryngomalacia after failed initial supraglottoplasty. Reasons for failing initial surgery can be a conservative initial supraglottoplasty or severe reflux with failure to comply with postoperative reflux protocol. Preoperative consultation is obtained with a pediatric gastroentrologist to perform a full gastrointestinal evaluation.
2. Instruments: Parsons laryngoscope, Medtronic MicroFrance Bouchayer Laryngeal instruments (heart shaped forceps, fine cup forceps, Micro Scissors curved right & left, micro suction), oxymetazoline soaked pledget
3. Landmarks: vallecula, epiglottis, aryepiglottic fold, cuneiform cartilage, interarytenoid space
4. Procedure:
a. Larynx sprayed with topical 2% lidocaine.
b. Parsons laryngoscope placed in the vallecula and in suspension and patient is intubated.
c. Aryepiglottic fold is redivided with a curved micro scissor at its attachment to the epiglottis. Division proceeds until the epiglottis is released and it springs anteriorly. (Special care should be taken to not divide the pharyngoepiglottic fold).
d. One side of the curved epiglottis is grasped with a small cup forcep or heart shaped forcep. The epiglottis is then trimmed with a curved scissor (mucosa and cartilage).
e. Hemostasis is achieved with an oxymetazoline soaked pledget.
f. The patient remains extubated and is transferred to the intensive care unit. The patient is given Decadron at a dosage of 0.5mg/kg every 8 hours for 24 hours following the procedure and twice daily proton pump inhibitor and reflux precautions for at least 30 days and then weaned off.
g. Clinical swallow evaluation is performed 4 hours postoperatively and patient resumes age appropriate diet.
h. Flexible fiberoptic laryngoscopy is performed one week postoperatively.
5. Conflict of interest: none.
6. References: none
DOI: http://dx.doi.org/10.17797/ag049330ri
Heineke – Mikulicz Strictureplasty in Crohn’s Disease
This video shows the performance of a Heineke – Mikulicz Strictureplasty in the treatment of stricturing Crohn’s disease of the small bowel.
DOI: http://dx.doi.org/10.17797/jj8ee1q3mr
Editor Recruited By: Jeffrey B. Matthews, MD
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
Gray Minithyrotomy
Contributors: Michael Lerner and Lucian Sulica
Gray Minithyrotomy with fat implantation
DOI: https://doi.org/10.17797/5p22fy2gkx
Endoscopic Excision of Nasolacrimal Duct Cyst
The patient is a 4 week old female infant with right sided epiphora and complete right sided nasal obstruction resulting in respiratory and feeding difficulty. Physical exam demonstrated a right medial canthal mass consistent with a dacrocystocele. Flexible fiberoptic nasal endoscopy demonstrated an anterior nasal mass below the inferior turbinate occluding the entire right nasal cavity consistent with a nasolacrimal cyst. The etiology is obstruction at the level of Hassner’s valve.