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

Endoscopic Repair of Tracheal-bronchial Sinus Tract

Contributor: Deepak Mehta (Children's Hospital of Pittsburgh) Endoscopic Repair of Tracheal-bronchial Sinus Tract: Clinical History: 6 year-old female with a history of tracheal-esophageal fistula s/p repair at birth and a right sided aortic arch. She has a recent history of 6 episodes of pneumonia requiring hospitalization. She had a normal modified barium swallow exam. CT chest revealed a tract arising from the posterior carina. Operative Course: The patient was taken to the OR and using a 5.0 rigid ventilating bronchoscope we are able to easily visualize the tracheal bronchial sinus tract originating from the posterior carina. A flexible suction catheter was used to probe the tract. It extended approximately 1.5cm. Then using a Urologic Bugbee electrocautery, we de- epithelialized the tract. Next, Tisseel fibrin sealant was injected into the tract, closing it off. The bronchoscope was removed and the patient was admitted overnight for observation. She did well with no desaturations or complications and was discharged home on post op day #1. DOI: http://dx.doi.org/10.17797/nqf3kv0qyp

Injection Laryngoplasty for Type 1 Laryngeal Cleft

Schools: Children's Hospital of Pittsburgh Injection Laryngoplasty for type 1 laryngeal cleft is done with first identifying the deep cleft by palpation of the interarytenoid notch. Once a confirmation is made the larynx is suspended with a laryngoscope. Radiesse voice gel is then primed in a laryngeal needle and the needle is placed at the apex of the cleft. The needle is then pushed to palpate the cricoid cartilage with the bevel of the needle pointing towards the esophageal surface. The needle is then slightly retracted and about 0.2 ml of voice gel is injected. Care is taken not to make multiple punctures and the subglottisis watched so that the injection does not inadvertently go into subglottis. DOI: http://dx.doi.org/10.17797/g5r116zy3n

Robotic Assisted Type 1 Laryngeal Cleft Repair

Contributors: Umamaheshwar Duvvuri (University of Pittsburgh Medical Center) A DaVinci Robot is used to dock in with a 30 degree up telescope.The oral cavity is exposed using a FK retractor or a modified McIvor mouth gag( one with a flat blade). Robotic 5 mm Maryland forceps and 5 mm monopolar diathermy forceps is used. After getting a good exposure of the laryngeal cleft the diathermy at a setting of 4-5 watts is used to make the incision.and using the maryland forceps the laryngeal and esophageal flaps are created.A 5.0 PDS suture with a P2 tapered needle is used.The apex of the esophageal flap is first closed with suturing it.After this the apex of the laryngeal surface is closed.For a laryngeal cleft repair 2-4 sutures are required to obtain a closure. The sutures on the laryngeal surface are buried.The patient is kept intubated for a day or two to avoid excess movement of larynx. Pre and post operative treatment of reflux is important for healing. DOI: http://dx.doi.org/10.17797/z17zngnuwp

Pediatric Robotic Epiglottopexy

This is a patient with persistant laryngomalacia with stridor and Obstructive sleep apnea at 3 years of age. A flexible laryngoscopy showed prolapse of epiglottis into the airway. The patient had nasotracheal intubation and a suture was place through the anterior tongue to pull it forward while a modified McIvor mouth gag was placed with a short blade to expose the tongue base and epiglottis. The DaVinci robot is then docked with a 30 degree forward lens. A 5mm maryland forceps and a 5 mm bovie is used.The epithelium off the tongue base and the lingual surface of epiglottis is then denuded with a bovie at a setting of 10 after this is done the epiglottis is sutured to the tongue base with a 4.0 vicryl suture. A total of two or three sutures are placed with 3-4 knots on each suture. The patient is extubated and monitered overnight with 2-3 doses of Steroids. DOI: http://dx.doi.org/10.17797/z6vqam37jc

Endoscopic Balloon Dilation of Tracheal Stenosis

A 16 year old presented with stridor three after being intubated for a week following a head injury. Endoscopy revealed a long segment tracheal stenosis in a subacute phase. The airway was sized with a uncuffed 3.5 endotracheal tube with a leak at 20cm of water.This stenosis was Grade 3 Cotton-Myer classification. A 12 mm Vascular balloon (Boston Scientific-Blue Max) was placed in the in the airway with direct visualization and was dilated at 20 atmospheres for about a minute. The patient was under general anaesthesia but spontaneously breathing throughout the procedure. The patient was sized to a 6.5 endotracheal tube with a free leak after the dilation. DOI: http://dx.doi.org/10.17797/n35d0ug41t

Adenotonsillectomy: Basic Technique Using Electrocautery

Contributors: Deepak Mehta (Children's Hospital of Pittsburgh of UPMC) Purpose: Adenotonsillectomy is a procedure removing the tonsils and ablating the adenoids. Most commonly this is performed when the tonsils and adenoids have become obstructive, causing sleep disordered breathing or sleep apnea, or are recurrently or chronically infected. Key Instruments: McIvor mouth gag, Curved and Straight Allis clamps, Monopolar electrocautery with insulated blade set at 15W for removal, suction monopolar cautery set at 35 for adenoidectomy and 20 for cauterization of the tonsillar fossa. Anatomical Landmarks: Anterior and posterior pillars of the tonsil, vomer, torus tubarius of the Eustachian tube. Procedure: Tonsillectomy begins by placing the McIvor mouth gag into the oral cavity. The soft palate is palpated to assess for submucous cleft palate. One tonsil is grasped with the Allis clamp and retracted medially. This allows identification of the lateral extent of the tonsil. A mucosal incision is made at or slightly medial to the lateral extent and the fascial plane is entered between the tonsil and the pharyngeal musculature. Continuing in this plane throughout the dissection, the tonsil is effectively removed. The posterior pillar must be preserved. Hemostasis of the tonsillar fossa is achieved using the monopolar electrocautery. The contralateral tonsil is removed similarly. Monopolar adenoidectomy is performed using indirect mirror visualization of the adenoid tissue. Suction electrocautery is used to ablate the adenoid tissue up to the posterior choana and lateral to the torus tubarius. Conflict of Interest: None DOI: http://dx.doi.org/10.17797/xaqg93x7hy

Epiglottopexy for Severe Laryngomalacia with Epiglottic Prolapse

Contributors: Deepak Mehta (Children's Hospital of Pittsburgh of UPMC) Laryngomalacia is the most common cause of stridor in newborn infants. The majority of cases resolve spontaneously. Common surgical therapy consists of division of the aryepiglottic folds combined with trimming of the arytenoid mucosa and/or cuneiform cartilages. Less frequently, epiglottopexy is required. Initially, flexible laryngoscopy illustrated prolapse of the epiglottis into the laryngeal lumen causing severe obstruction. Microlaryngoscopy, bronchoscopy, and supraglottoplasty (division of the aryepiglottic folds only) were performed, however improvement did not occur due to persistent epiglottic prolapse. Transoral epiglottopexy was performed. A Lindholm laryngoscope was used for exposure. A needle point cautery was used to remove the mucosa of the lingual surface of the epiglottis and the base of tongue. Alternatively, a carbon dioxide laser could used. 5-0 polydioxanone suture on a P-2 needle was to suspend the epiglottis to the base of tongue using 3 sutures. Photographs of the suspension conclude the procedure. DOI: http://dx.doi.org/10.17797/locmhv8x9q

Robotic Assisted Pediatric Lingual Tonsillectomy

The patient is nasotracheally intubated with a regular cuffed nasotracheal tube. Using a modified McIvor mouth gag, the oral cavity is exposed with the tip of the blade just shy of the posterior 1/3 of tongue so that the tongue base is clearly visualized. The DaVinci robot is set in and using a 5 mm forceps and a mono polar diathermy the incision is made in the midline and the lingual tonsil is dissected out as it is peeled off from the tongue base muscles which is very clearly visualized. The forceps is used to gently retract the tissue while the bovie at a setting of 15 is used to remove the lingual tonsils.. At the end the operative site is irrigated to check for any bleeders. FLOSEAL is also applied to help in hemostasis. DOI: http://dx.doi.org/10.17797/q82n9gkkvs

Endoscopic Tracheoesophageal Fistula Repair

Contributors: Noemie Rouillard-Bazinet, MD and Deepak Mehta, MD Endoscopic repair of tracheoesophageal fistula using electrocautery and fibrin glue. DOI: http://dx.doi.org/10.17797/uq9ifhudgd Editor Recruited By: Sanjay Parikh, MD, FACS

Rib Cartilage Harvest for Laryngotracheal Reconstruction

Contributors: Deepak Mehta This video depicts how to harvest a rib cartilage graft for use in pediatric laryngotracheal reconstruction for airway stenosis. DOI# http://dx.doi.org/10.17797/oo77838cxt Authors Recruited By: Deepak Metha

Management of subglottic stenosis with endoscopic stent placement

History of airway stenosis, s/p laryngotracheal reconstruction. Developed restenosis, and balloon dilated three times.

In this video we describe our technique for airway stent insertion and its securing to the neck skin.

Balloon dilation of the airway expanded the airway to its appropriate size. After sizing, an 8mm modified Mehta laryngeal stent with rings (Hood Laboratories, Pembroke, Mass., USA)is inserted in the airway with laryngeal forceps. The scope is inserted into the stent to verify its position. Then a 2.0 prolene stitch is taken through the neck, trachea, stent, and taken out through the contralateral skin. This is performed under visualization with a 2.3mm endoscope through the stent. The needle is then re-inserted through the exit puncture and again taken out next to the entry puncture after passing through a subcutaneous tunnel, without re-entering the stent. A small skin incision is performed between the two prolene threads. Multiple knots are taken over an angiocath, which is then buried under the skin.

The stent is taken out 2-6 weeks after the procedure. A neck incision is performed, the angiocath is identified, the knot is cut and the stent is removed under the vision of the endoscope.

Closure of H-type tracheoesophageal fistula

We present the case of a 20 months old boy with developmental delay and chromosomal abnormality, who presented with a history of chronic aspiration. He was found to have a laryngeal cleft, which was injected with Prolaryn, then formally repaired, twice. Despite an initial a negative swallow study, the patient had persistent aspiration. A repeat direct laryngoscopy and bronchoscopy finally revealed the presence of an H-type tracheoesophageal fistula (TEF). We describe here the steps of the surgical repair of an H-type tracheoesophageal fistula.

Deepak Mehta

• Director, Pediatric Aerodigestive Center – Texas Children’s Hospital
• Professor of Otorhinolaryngology – Baylor College of Medicine

Dr. Mehta’s clinical interests are complex airway surgery, pediatric swallowing disorders and head and neck masses,along with general otolaryngology. His research interest includes outcomes of airway surgery, laryngeal cleft management and outcomes of sleep disorders.

Best of CSurgeries

Drs. Andrew Scott, Evan Propst, Gresham Richter, & Deepak Mehta highlight surgical techniques on the website and go over the videos depicting these common procedures.

Covid-19 Impact on Anesthesia and Aero-Digestive Surgeries

Please join us for an interactive webinar on a variety of topics related to COVID 19. Organized by the Amrita Institute of Medical Sciences and Research Centre, Kochi, Kerala, India and moderated by Dr. Jayanthy Pavithran, Dr. Deepak Mehta, and Dr. Kishore Sandu, this panel will discuss the following topics:

1. Practical tips for endoscopy and use of powered instruments. | Presented by Dr. Deepak Mehta, Director, Pediatric Aerodigestive center and Dr. Shasidhar Tatavarthy, Senior consultant, Head, Ent Head Neck surgery Artemis Hospitals, Delhi

2. Psychiatry and C19. | Presented by Dr. Kusum Kathpalia (NY State)

3. Covid 19: An anesthetist’s view point from its pathogenesis to future airway interventions. | Presented by Dr. Patrick Schoettker, Medecin Chef- Anesthesia department. Lausanne University Hospital. Switzerland

4. Airway surgeries during Covid times. | Presented by Dr. Kishore Sandu, Medecin Chef, ORL department, Lausanne University Hospital. Switzerland.

5. Albatross Cases In Airway. | Presented by Dr. EV Raman , Consultant ENT Surgeon, Convenor, Children’s Airway and Swallowing Center ( CASC),Manipal Hospital, Bangalore and Dr.Rakesh Srivastava, Senior Consultant (Laryngologist, Sushrut Institute of Plastic Surgery & Super speciality Hospital, Lucknow, India.

This webinar is geared towards: airway surgeons (adult & pediatric), laryngologists, ENT, anesthesiologists and phoniatricians (SLP).

For more info on the CSurgeries webinar series, please go to www.csurgeries.com

The Ins and Outs of Medical Research & Publication

The International Journal of Medical Students and CSurgeries have come together to provide and exclusive inside scoop on the world of medical publications. They will review how to properly research and submit an article along with selecting the best journal to publish through.