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.
Contributors: Adam Johnson, MD and Gresham Richter, MD, FACS Noninvovluting Congenital Hemangioma (NICH) is a congenital vascular lesion present at birth. These lesions do not regress, in contrast to infantile hemangioma or Rapidly Involuting Congenital Hemangioma (RICH), and may grow proportionately with age. Most lesions present in the head and neck, trunk, or limbs, and can be painful. Surgical excision is the treatment of choice. DOI #: http://dx.doi.org/10.17797/5hq5nro3j4
This is a visual representation of the treatment of a venous malformation within the substance of the tongue. The laser directly treats the venous malformation via selective photothermolysis while preventing injury to the tongue itself. Venous malformations infiltrate normal tissue as a birthmark but continue to grow with time and show no evidence of regression. Instead of excising the venous malformation with some of the tongue itself this is a way of controlling the lesion. As seen, the ND:YAG laser set at 25 Watts and 1.0 sec duration is used to shrink the venous malformation. The laser is fired in a polkadot fashion in order to prevent mucosal sloughing. The surface is relatively protected as the laser selective penetrates the VM. DOI: http://dx.doi.org/10.17797/938qzyj3uh
Infantile hemangiomas are vascular tumors composed of proliferating endothelial cells. They uniquely undergo rapid expansion from birth to 6-8 months of age and subsequent slow dissolution over several years thereafter. Some hemangiomas are at risk of causing functional problems during their growth phase as seen in this upper eyebrow lesion obstructing the visual axis. Laser, surgical and medical treatment options are available for problematic hemangiomas. This patient was elected to undergo excision to completely remove the lesion and forego a long course of medical therapy (propranolol). Because of the their vascular nature, excision of hemangiomas requires careful planning and hemostasis. The hemangioma is marked in elliptical fashion along natural aesthetic facial lines along the brow. The inferior mark in incised first. Careful subdermal dissection is critical to completely excise to the hemangioma near the surface and find the appropriate plane. Control of bleeding is maintained by monopolar and bipolar electrocautery as well as dissecting the lesion from one side and alternating to the other. The plane of deep dissection is rarely below the subcutaneous layer thus protecting important nerves and vessels. Complete removal is possible. Closure is performed with dissolvable monocryl or PDS suture with dermabond superficially. A plastic eyeshield (blue) is placed at the beginning of case to protect the patient's cornea during the procedure. DOI: http://dx.doi.org/10.17797/zlvhux8afu
Contributors: Conor Smith (Arkansas Children's Hospital) and Gresham Richter M.d. (Arkansas Children's Hospital) The removal of tonsils is most often indicated by tonsillar hypertrophy contributing to obstructive sleep apnea or chronic/recurring throat infections from pathogens such as streptococcal bacteria. Electrocautery is the most commonly used technique to safely and effectively excavate the tonsils. DOI: http://dx.doi.org/10.17797/cb233d20mk
Contributors: Gresham Richter Here we present endoscopic excision of a concha bullosa (a pneumatized middle turbinate) that was causing obstruction in the left nasal cavity. This particular patient failed medical management of his chronic sinusitis including antibiotic and steroid therapy. The concha bullosa was causing obstruction of the maxillary sinus ostium and deviation of the nasal septum. Resection of the concha bullosa was necessary in order to complete a functional endoscopic sinus surgery afterward and septoplasty (not shown). DOI # 10.17797/pyzfxehca8 Author Recruited by: Gresham Ritcher
Contributors: Juliana Bonilla-Velez and Gresham Richter This patient presented with an anterior neck mass that was mobile with tongue movement. This is consistent with a thyroglossal duct cyst. The following video demonstrates the excision of a thyroglossal duct cyst using the Sistrunk procedure. DOI#: http://dx.doi.org/10.17797/oelc9n6wlc
Introduction Lymphatic malformations (LM) are composed of dilated, abnormal lymphatic vessels classified as macrocystic (single or multiple cysts >2 cm3), microcystic (<2 cm3), or mixed. This patient is a 5-month-old with a right neck mass consistent with macrocystic lymphatic malformation on MRI. This low-flow vascular malformation required surgical intervention. Methods The site was marked in a natural skin crease. Subplatysmal flaps were raised and malformation was immediately encountered. Blunt soft tissue dissection was performed immediately adjacent to the mass to reflect tissue off the fluid-filled lesion. Neurovascular structures were preserved in this process. Mass was removed in total and Penrose drain and neck dressing were placed. Results A complete resection was performed. LM was confirmed on pathology. Patient is doing well with no deficits noted. The drain was removed after 1 week. One-month follow-up showed no recurrence. Conclusion Macrocystic lymphatic malformations are amenable to surgical resection at low risk and without recurrence. By: Ravi W Sun, BE Surgeons: Luke T Small, MD Gresham Richter, MD 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 Recruited by: Gresham T Richter, MD
Tympanoplasty with tragal cartilage graft, postauricular approach Blake Hollowoa, Michael Kubala, Gresham Richter. Introduction Tympanic membrane (TM) perforations arise from multiple conditions including acute otitis media, barotrauma, chronic eustachian tube dysfunction, or as a complication of pressure equalization (PE) tube insertion. Most perforations heal spontaneously or with conservative measures such as ototopical drops and dry ear precautions. Perforations that do not heal can lead to conductive hearing loss, chronic infection, or cholesteatoma. A 6-year-old patient with a persistent TM perforation presented with otalgia and otorrhea. A tympanoplasty with a tragal cartilage graft was performed to repair the patient’s TM perforation. Methods The patient was intubated and the operation carried out under general anesthesia. Facial electrodes were inserted for facial nerve monitoring. The patient was prepped and draped in sterile fashion. The external canal was suctioned and irrigated. A tragal incision was then made to harvest a 1 cm piece of cartilage for the TM graft. The tragal incision was closed with monocryl suture. A postauricular incision was made in the natural skin crease to expose the posterior canal. Canal incisions were made to enter the external canal. A tympanomeatal flap was elevated until the middle ear was entered. The previously harvested tragal cartilage graft was inserted medial to the native TM perforation. Gel-Foam was inserted medial to the graft for support. Tragal perichondrium was inserted lateral to the tragal cartilage graft. Gel-Foam was then inserted lateral to the graft for support. The periosteum and postauricular incision were closed with vicryl suture. The external canal was inspected, then antibiotic ointment and an ear wick was inserted. The patient was dressed using a Glasscock dressing. Results The patient was discharged the same day and seen in clinic two weeks from his surgery. The incisions were healing well with no indications of infection or wound dehiscence. His pain was resolved and an appointment for formal audiology was scheduled for a 3-month follow-up visit. Conclusion Tympanoplasty with a tragal cartilage graft using a postauricular approach is a successful method to surgically correct persistent tympanic membrane perforations.
The following video demonstrates the authors' method for performing a tracheostomy in a pediatric patient. Details of important anatomical landmarks and surgical technique are demonstrated in the video. Authors: Chrystal Lau, BA. University of Arkansas for Medical Sciences. Brad Stone, BA. University of Arkansas for Medical Sciences. Austin DeHart, MD. Arkansas Children's Hospital. Michael Kubala, MD. University of Arkansas for Medical Sciences. Gresham Richter, MD. Arkansas Children's Hospital.
Laryngeal Papillomatosis with Microlaryngoscopy and Bronchoscopy with Microdebridement, CO2 Laser Ablation, and Cidofovir Injections.video
Anna Celeste Gibson, B.S., Mariah Small, M.D., Gresham Richter, M.D. University of Arkansas for Medical Sciences, Arkansas Children's Hospital Introduction: A papilloma is a benign tumor that is caused by human papillomavirus (HPV) commonly due to the strains 6 and 11. Children acquire these tumors intrapartum from an infected mother. HPV infects natural and metaplastic squamous mucosa which is the type of epithelium that lines the vocal folds. Tumors present as numerous, verrucous outgrowths from the mucosa and can become symptomatic due to mass effect. Common symptoms include hoarseness, dysphonia, aphonia and most concerning, respiratory distress. A 7-year-old patient with dysphonia secondary to laryngeal papillomatosis also known as recurrent respiratory papillomatosis undergoes microlaryngoscopy and bronchoscopy with microdebridement, CO2 laser ablation, and cidofovir injections. Methods: The patient underwent spontaneous ventilation anesthesia and a dental guard was placed. The patient was positioned for microlaryngoscopy and the larynx was visualized and anesthetized with topical lidocaine. A zero-degree Hopkins rods was passed through the supraglottis, glottis and subglottis to document findings. There was supraglottic papillomatosis notably of the laryngeal surface of the left epiglottis, papillomatosis of the bilateral false vocal folds and papillomatosis of the bilateral true vocal folds with right more affected than left and anterior commissure involvement. The scope was then withdrawn and reintroduced to perform bronchoscopy. The scope was advanced through the trachea, carina and primary and secondary bronchi bilaterally. All were within normal limits. The Benjamin-Lindholm laryngoscope was passed into the vallecula and larynx and suspended in a normal fashion. The zero-degree Hopkins rod was used to visualize the larynx. 2 cc of 1% lidocaine with 1:100,000 epinephrine was injected into the bulk of the papillomas and then several biopsies were taken from this area. The microdebrider was used to debulk these areas. Protective eyewear was used by everyone in the operating room. The patient's face was protected with water soaked towels and all oxygen sources were removed from the patient. The CO2 laser was set to 2 watts continuous and used to debulk the papillomas with eschar noted after each application. Care was taken to avoid injury to the deep elements of the true vocal folds. Any residual papillomas at the anterior vocal folds were then injected with 1 cc of cidofovir. All instrumentation was removed, the patient was extubated, awakened, and transferred to the recovery room. Results: The patient was discharged the same day without complications. He will follow up for revision microdebridement, CO2 laser ablation and cidofovir injections. Conclusion: Microlaryngoscopy and bronchoscopy with microdebridement, CO2 laser ablation, and cidofovir injections is a successful solution for laryngeal papillomatosis and has been proven to eradicate the disease in many cases.
8 AM EST / 6:30 PM IST
Moderator: Gresham Richter
Panelists: Goh Bee-See, Hayley Herbert, Ravi Thevasagayam, Sohit Kanotra and Dana Thompson
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Drs. Gresham Richter, Dana Thompson, Jessica Levi, and Jeffery Simons explore the new and growing trends in the realm of reflux and swallowing. They review how to diagnose the different variants along with how to treat them.
Drs. Andrew Scott, Evan Propst, Gresham Richter, & Deepak Mehta highlight surgical techniques on the website and go over the videos depicting these common procedures.
Meet Gresham Richter ─ Professor, Academic Surgeon and Co-founder of CSurgeries
(Better known as “G” to his colleagues at CSurgeries).
Q: How did CSurgeries get started? How did you come up with idea?
A: CSurgeries was originally developed to be an educational surgical outlet that was video based- to teach trainees how to perform the surgeries or at least ask the appropriate questions during the procedure. It was going to be a CD-based system, but then we realized we wanted to expand the market, not just for residents, but for everyone…students, patients and other surgeons alike. We wanted to capture details for every field and do it on a grand scale, applicable to a bigger audience.
With this goal in mind, CSurgeries became a web-based venue. To encourage publication, we wanted to make this a win-win for the surgeons taking the time to produce the video. Our answer was simple. Our “aha” moment, so to speak was… the videos submitted by our colleagues must be a peer reviewed publication where credit is given and the videos are validated.
Q: What can you tell me about CSurgeries that’s not on the website?
A: It’s an amazing site! It’s the perfect opportunity for surgical educators and anyone else trying to learn about a particular surgery or technique. Surgical leaders from around the world are involved. There is so much activity already happening on CSurgeries.com. Patients, students, and expert surgeons are exploring the posted peer-reviewed cases.
Q: What makes CSurgeries unique?
A: We are unique in so many ways, but really it’s the people behind CSurgeries team that make us unique. We are an academic physician owned and operated organization. Our mission as is to teach and we understand how to value video content for publication. We have brought in education leaders in each specialty who are hands-on ─ participating, editing, and overseeing the videos produced and published on the site. It has become clear also that those submitting are interested in authoring videos to teach, not just to have something on the internet.
We understand that in the area of academic surgery, publication is critical. We allow surgeons, and their trainees, to get academic credit for their high quality and annotated videos of procedures; each of our videos is peer –reviewed and as a result we are being recognized as the premier site for validating their procedures with a publication. In fact, each video that gets approved get assigned its own DOI publication number. Companies like Research Gate already recognize our videos as a publication. Soon we head for PubMed and other Medline search engines…
Q: You are a surgeon. You are a teacher. You are an entrepreneur. Do you sleep?
Just enough. I have a very regimented schedule between family and work. Up early, home for dinner, kids to bed by 8pm and then I get right to work. Consistency helps. Family is critical. Thus sometimes I’m late to our late team conference calls!
Q: What advice would you give a medical student thinking about becoming a surgeon?
It’s a wonderful world and life…very rewarding. More importantly, learn as much as you can by observing and operating as much as possible.
Q: What would you be doing, career-wise, if you didn’t become surgeon?
I actually went to med school to become a psychiatrist but I realized that I was simply not patient enough. Honestly, I think I would be in the business world one way or another. Fortunately, now I have a mix of both. Like they say they in Arkansas, sometimes a blind squirrel finds a nut.
Q: Where do you see surgical education headed…let’s say in the next 10-15 years?
Streaming education and no more books. On-line interactive education with video and chat. In this sense, surgical education is going to follow internet advances.
Have a question you would like to ask Dr. Richter? Feel free to post a comment or send him an email at email@example.com
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