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Pediatric Tracheostomy
video

Paediatric Tracheostomy Position the child with chin extension appropriately Drape the child as shown in the video Mark the incision line Use 15 number blade for skin incision Remove the excessive subcutaneous fat tissue Find the median raphe and strap muscles Retract the strap muscles laterally Identify the tracheal ring Create the impression of tube for appropriate size incision Place the stay sutures as shown in the video incise the trachea with 11 number blade Secure the maturation sutures Insert the tracheostomy tube Confirm the position and then inflate the cuff Secure the ties and dressing at the end.

Microdebrider Assisted Lingual Tonsillectomy
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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.

Congenital Nasal Pyriform Aperture Stenosis (CNPAS): Sublabial Approach to Surgical Correction
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Congenital nasal pyriform aperture stenosis (CNPAS) is defined as inadequate formation of the pyriform apertures forming the bony nasal openings resulting in respiratory distress and cyanosis soon after birth. Some clues such as worsening distress during feeding and improvement during crying may indicate a nasal cause of respiratory distress rather than distal airway etiology. Inability or difficulty passing a small tube through the nasal cavities may suggest CNPAS. The presenting clinical features of CNPAS can be similar to other obstructive nasal airway anomalies such as choanal atresia. Diagnosis is confirmed via CT scan with a total nasal aperture less than 11mm. CNPAS may occur in isolation or it may be a sign of other developmental abnormalities such as holoprosencephaly, anterior pituitary abnormalities, or encephalocele. Some physical features of holoprosencephaly include closely spaced eyes, facial clefts, a single maxillary mega incisor, microcephaly, nasal malformations, and brain abnormalities (i.e. incomplete separation of the cerebral hemispheres, absent corpus callosum, and pituitary hormone deficiencies). It is important to rule out other associated abnormalities to ensure optimal treatment and intervention. Conservative treatment of CNPAS includes humidification, nasal steroids, nasal decongestants and reflux control. Failure of conservative treatment defined by respiratory or feeding difficulty necessitates more aggressive intervention. The most definitive treatment for CNPAS is surgical intervention to enlarge the pyriform apertures. Contributors: Adam Johnson MD, PhD Abby Nolder MD

Mandibular Distraction for Micrognathia in a Neonate
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Introduction Patients with Pierre-Robin Sequence (PRS) suffer from micrognathia, glossoptosis, and upper airway obstruction, which is sometimes associated with cleft palate and feeding issues. To overcome these symptoms in our full-term male neonate patient with PRS, mandibular distraction osteogenesis was performed. Methods The patient was intubated after airway endoscopy. A submandibular incision was carried down to the mandible. A distractor was modified to fit the osteotomy site that we marked, and its pin was pulled through an infrauricular incision. Screws secured the plates and the osteotomy was performed. The mandible was distracted 1.8 mm daily for twelve days. Results During distraction, the patient worked with speech therapy. Eventually, he adequately fed orally. He showed no further glossoptosis or obstruction after distraction was completed. Conclusion In our experience, mandibular distraction is a successful way to avoid a surgical airway and promote oral feeding in children with PRS and obstructive symptoms. By: Ravi W Sun, BE Surgeons: Megan M Gaffey, MD Adam B Johnson, MD, PhD Larry D Hartzell, 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

Superiorly Based Pharyngeal Flap for Velopharyngeal Dysfunction
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Velopharyngeal dysfunction (VPD) refers to the improper control of airflow through the nasopharynx. The term VPD denotes the clinical finding of incomplete velopharyngeal closure. Other terms used to describe VPD include velopharyngeal insufficiency, inadequacy and incompetence. However, the use of VPD has gained popularity over these terms as they may be used to infer a specific etiology of impaired velopharyngeal closure.1 Control of airflow through the nasopharynx is dependent on the simultaneous elevation of the soft palate and constriction of the lateral and posterior pharyngeal walls. Disruptions of this mechanism caused by structural, muscular or neurologic pathology of the palate or pharyngeal walls can result in VPD. VPD can result in a hypernasal voice with compensatory misarticulations, nasal emissions and aberrant facial movements during speech.2 The assessment of velopharyngeal function is best preformed by a multispecialty team evaluation including speech-language pathologists, prosthodontists, otolaryngologists and plastic surgeons. The initial diagnosis of VPD is typically made with voice and resonance evaluation conducted by a speech-language pathologist. To better characterize the patient’s VPD, video nasopharyngeal endoscopy or speech videofluoroscopy can be used to visualize the velopharyngeal mechanism during speech. VPD may first be managed with speech-language therapy and removable prostheses. For those who are good surgical candidates and do not fully respond to speech-language therapy, surgical intervention may be pursued. Surgical management of VPD is most commonly accomplished by pharyngeal flap procedures or sphincter pharyngoplasty. In this video, a superiorly based pharyngeal flap with a uvular mucosal lining flap was preformed for VPD in a five-year-old patient with 22q11 Deletion Syndrome and aberrantly medial internal carotid arteries.

Neonatal Mandibular Distraction Osteogenesis with Multivector External Devices
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Pierre Robin sequence (PRS) is a craniofacial malformation characterized by micrognathia and glossoptosis, with or without cleft palate. A subset of infants with PRS will suffer from airway obstruction severe enough to merit surgical intervention. Surgeries for PRS include tongue lip adhesion, tracheotomy, gastrostomy, and bilateral mandibular distraction osteogenesis. Distraction osteogenesis refers to a process in which a bone is lengthened after an initial osteotomy by means of separating the two resulting segments slowly over time. In the neonatal mandible, hardware used for distraction may be implanted beneath the skin or affixed externally. Each device has its advantages and disadvantages, however external devices are less expensive, do not typically require preoperative computed tomography scanning, may be adjusted easily throughout the distraction process, and are easily removed following consolidation, avoiding a second invasive procedure and lengthy anesthetic. This video presents the technique of neonatal mandibular distraction osteogenesis using multivector external distractors.

Endoscopic Grade 4 Subglottic Stenosis
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We describe the management of a grade 4 subglottic stenosis, which was successfully performed endoscopically. This is the case of a 17 year-old female, tracheostomy dependent, with a complex history of failed open airway surgeries. Patient was referred to our center for a second opinion for decannulation. We found a grade 4 subglottic stenosis at her initial evaluation with a prolapsed anterior graft. Patient and family requested an endoscopic procedure, trying to avoid another open surgery. It was decided that an endoscopic procedure would be attempted. Patient was placed into suspension, and using alligator forceps, the stenotic area was probed until communication could be made with the distal tracheal. Using a series of balloon dilations and the microdebrider, a suprastomal stent could be endoscopically placed. Stent was removed 6 weeks later and showed a patent airway. Patient then underwent a series of 4 dilations and was successfully decannulated, just before graduating from college.

Endoscopic Repair of Type IIIB Posterior Laryngeal Cleft
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We present a case of a type IIIB posterior laryngeal cleft treated successfully with endoscopic repair.

Extended Partial Cricotracheal resection with thyrotracheal anastomosis in Grade IV subglottic stenosis with posterior glottic involvement
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The video goes over the steps of an extended partial Cricotracheal resection in a 8 year old child with Grade 4 subglottic stenosis with posterior glottis involvement.

Management of subglottic stenosis with endoscopic stent placement
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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.

Transoral incision and drainage of retropharyngeal abscess.
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Authors: Matthew Kim, Vikash Modi. This is a demonstration of transoral incision and drainage of retropharyngeal abscess in a 5-year-old male who presented with fever and neck stiffness. An initial CT scan with intravenous contrast showed retropharyngeal edema without organized abscess. A repeat scan 4 days later revealed a peripherally enhancing, multi-loculated hypodense collection centered in the left retropharyngeal space. After induction of general anesthesia and orotracheal intubation with a 4.5 cuffed oral RAE endotracheal tube, the patient is placed in suspension with a Crowe-Davis mouth gag. The abscess forms a noticeable bulge in the posterior pharyngeal wall. A flexible suction catheter is passed through the right nasal cavity and used to retract the soft palate and uvula to maximize exposure. After retracting the tonsillar pillars laterally with a Hurd elevator, a Beaver 6400 mini blade is used to make a vertical incision in the pharyngeal mucosa centered over the abscess. There is immediate return of purulence – a culture swab is used to obtain a sample for microbiological testing. A Yankauer suction bluntly enlarges the opening while simultaneously suctioning out purulent debris. The incision is widened superiorly and inferiorly with curved Metzenbaum scissors. Spreading the instrument vertically minimizes risk of vascular injury. An Adson clamp is then used to bluntly explore the abscess cavity laterally and superiorly. Further purulent drainage is expressed. The abscess cavity is further explored and widened with digital dissection. The abscess cavity is copiously irrigated with saline. After confirming hemostasis, the patient was extubated uneventfully. He was started on an oral diet immediately after surgery and discharged the following day.

Pediatric Tracheostomy
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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.

Microlaryngoscopy, Bronchoscopy + Supraglottoplasty in COVID-19 Era
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This video demonstrates microlaryngoscopy, bronchoscopy (MLB) + supraglottoplasty in a three-month old male with laryngomalacia, with a special focus on appropriate personal protection equipment (PPE) and safe surgical considerations in the setting of a COVID-19 status unknown patient.

Closure of H-type tracheoesophageal fistula
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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.

Endoscopic resection of a vallecular cyst in a pediatric patient
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Base of tongue masses are rare in the pediatric population, when present they can be remain asymptomatic for years or can cause acute respiratory distress. The differential diagnosis includes dermoid, vallecular cyst, thyroglossal duct cyst, lingual thyroid, lymphangioma, hemangioma, and teratoma (1). Vallecular cysts consist of mucus filled cysts or pseudocysts arising either from the mucosa on the lingual surface of the epiglottis or on the base of tongue (2). These benign mucous retention cysts most commonly present as stridor, difficulty feeding, respiratory distress but they can also remain asymptomatic and can be found incidentally (3,4). Vallecular cysts may occur in isolation, but they can be associated with laryngomalacia and GERD in a significant number of patients(5). Initial screening of the airway is done using flexible fiberoptic laryngoscopy which provides a quick assessment of the larynx and visualization of the cyst(6). Imaging (ultrasonography, CT, MRI) can also be useful for evaluation of the mass and more detailed visualization of the mass and surrounding structures(6). Conservative medical treatment is not adequate for the management of vallecular cysts. Several surgical options have been described, these include aspiration, transoral endoscopic excision, marsupialization and deroofing with CO2 laser or microdebrider (6). There is a high recurrence rate when simple aspiration is performed (7), and there is reported risk of recurrence with marsupialization techniques. Excision using transoral endoscopic technique ensures complete resection with adequate visualization and preservation of surrounding structures and mucosa with low risk of recurrence (4). Here, we describe transoral endoscopic approach for excision of base of tongue cyst in a 3 year-old female. The patient presented with the diagnosis of PFAPA and she was seen to discuss tonsillectomy and adenoidectomy. On physical exam, a 1.5 cm midline base of tongue cyst was seen when she protruded her tongue. The cyst had been increasing in size. Plan was to proceed with tonsillectomy & adenoidectomy and excision of base of tongue cyst. After informed consent was obtained, the patient was brought to the operating room and placed supine on the operating table. Correct patient and procedure were identified and general anesthesia by mask was induced. A laryngeal mask airway was placed first. A red rubber catheter was placed through the left nostril after the Davis mouth gag was inserted with a small tongue blade. The soft palate and uvula were palpated to be normal. The adenoid was mildly enlarged and was cauterized completely with suction cautery. Following that, Afrin was placed in the nasal cavity. The child was intubated with a nasotracheal tube through her left nostril that allowed for exposure. A red rubber catheter was left in her right nostril. The side-biting mouth gag was used. Two separate 2-0 silk sutures were placed in the midline to retract her tongue. A 30-degree telescope was used for visualization of the base of tongue cyst. With the Hurd elevator and other means of retraction, an extended Colorado needle tip with a 45 degree bend at the distal portion, was used to completely remove the base of tongue cyst which was quite deep. At the distal part, there was mucus seen, but the cyst was completely excised. The wound was irrigated thoroughly. There was no bleeding. The side-biting mouth gag was removed and the Davis mouth gag reinserted. A complete tonsillectomy was then performed. She was then extubated without difficulty in the OR and transferred to PACU. Patient was discharged on oxycodone and amoxicillin. On her follow up visits, the oral cavity and tongue were healing well with no evidence of recurrence. Pathology result: consistent with extravasation mucocele. Mucin filled cystic space rimmed by a lympho-histiocytic reaction and granulation tissue. Minor salivary glands w/ dilated ducts focally surrounded by chronic inflammation are present in the surrounding fibromuscular tissue.

How to perform a Tracheostomy on an infant
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Authors Gilberto Eduardo Marrugo Pardo Titular professor, Department of Otorhinolaryngology, Universidad Nacional de Colombia, Bogotá, Colombia. Fundación hospital de la misericordia. gemarrugop@unal.edu.co JuanSebastián Parra Charris Department of Otorhinolaryngology, Universidad Nacional de Colombia, Bogotá, Colombia jusparrach@unal.edu.co    

Base of Tongue Reduction: Endoscopic Approach vs. Transoral Robotic Surgical Approach
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The video demonstrates successful endoscopic coblation of lingual tonsils and residual palatine tonsils as well as successful TORS reduction of obstructive base of tongue tissue.

Pediatric Tracheostomy with Maturation Sutures
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Procedure: This video demonstrates the operative method of pediatric tracheostomy with maturation sutures of the tracheocutaneous fistula tract. Introduction: Pediatric tracheostomy provides an alternate airway. Indications: This procedure is done to alleviate upper airway obstruction, facilitate prolonged mechanical ventilation, or pulmonary toilet. Contraindications: There are no absolute contraindications to this procedure, however, like any procedure, it has recognized possible risks. Conclusion: Pediatric tracheostomy with maturation sutures provides an alternate airway to bypass obstruction, facilitate long term ventilation, or pulmonary toilet.

Supraglottoplasty and Epiglottopexy for Sleep-Variant Laryngomalacia
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Here we present a 6-year-old girl with sleep-variant laryngomalacia treated successfully with endoscopic epiglottopexy and supraglottoplasty. Johanna L. Wickemeyer, MD1 Sarah E. Maurrasse, MD2,3 Douglas R. Johnston, MD, FACS2,3 Dana M. Thompson, MD, MS, FACS2,3 1Department of Otolaryngology—Head & Neck Surgery, University of Illinois—Chicago, 1855 West Taylor Street, Chicago, IL 60612 2Division of Pediatric Otolaryngology—Head and Neck Surgery, Ann and Robert H. Lurie Children’s Hospital of Chicago, 225 E. Chicago Ave, Chicago, IL 60611 3Department of Otolaryngology-Head and Neck Surgery, Northwestern University Feinberg School of Medicine, 420 E Superior St, Chicago, IL 60611

Transcervical Epiglottopexy for management of Type 3 Laryngomalacia
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Type 3 Laryngomalacia (LM) is characterized by prolapse of the epiglottis into the airway. Endolaryngeal suturing is technically challenging considering the limited exposure. In the present article we describe a simple technique of Transcervical Epiglottopexy (TE) via an exo-endolaryngeal technique, using an 18-gauge needle prethreathed with a 2-0 prolene suture in a looped fashion inserted through the inferior epiglottis. Another 20 G needle with a 2-0 prolene suture, with one free end is inserted above the previous stitch through the superior epiglottis. The single stitch is passed through the looped stitch, which is then pulled through the neck, leaving a single stitch precisely placed through the epiglottis. We have used this technique safely while achieving epiglottopexy in 3 cases of epiglottic prolapse. We describe a method of Transcervical Epiglottopexy using easily available instruments. This method we believe can easily be adapted for any kind of epiglottic prolapse.

Direct Laryngoscopy and Bronchoscopy: Purpose & Setup
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This video is an introduction to operative direct laryngoscopy and bronchoscopy (DLB) and will demonstrate 1) How to set up the equipment for a safe and comprehensive DLB and 2) How to assemble a rigid bronchoscope. Authors: Alexander Moushey1; Taher Valika, MD2; Erik H. Waldman, MD3; Sarah E. Maurrasse, MD3 Voiceover: Vidal Maurrasse 1Yale School of Medicine, New Haven, CT 2Department of Surgery, Division of Pediatric Otolaryngology, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine 3Department of Surgery, Section of Pediatric Otolaryngology, Yale School of Medicine, Yale New Haven Children’s Hospital

Endoscopic Repair of Unilateral Choanal Atresia
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This video provides background information regarding the diagnosis and management of choanal atresia and demonstrates the endoscopic repair of a unilateral choanal atresia. Authors: Alexander Moushey1; Kiley Trott, MD2; Sarah E. Maurrasse, MD2 Voiceover: Vidal Maurrasse 1Yale School of Medicine, New Haven, CT 2Department of Surgery, Section of Pediatric Otolaryngology, Yale School of Medicine, Yale New Haven Children’s Hospital

Direct Laryngoscopy and Bronchoscopy: Performing a Diagnostic Exam
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This video is an introduction to operative direct laryngoscopy and bronchoscopy (DLB) and demonstrates how to perform a safe and comprehensive exam in the operating room. Authors: Alexander Moushey1; Taher Valika, MD2; Erik H. Waldman, MD3; Sarah E. Maurrasse, MD3 Voiceover: Vidal Maurrasse 1Yale School of Medicine, New Haven, CT 2Department of Surgery, Division of Pediatric Otolaryngology, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine 3Department of Surgery, Section of Pediatric Otolaryngology, Yale School of Medicine, Yale New Haven Children’s Hospital

Single Stage Laryngotracheal Reconstruction with Anterior Cartilage Graft
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Single Stage Laryngotracheal Reconstruction with Anterior Cartilage Graft Leandro Socolovsky BA1, Rhea Singh BS1, Rajanya S. Petersson MS, MD1,2 1Virginia Commonwealth University School of Medicine, Richmond, VA 2Children’s Hospital of Richmond at VCU, Richmond, VA Overview This is a case of a 3-year-old male, former preterm infant born at 24 weeks with a past medical history of bronchopulmonary dysplasia and tracheomalacia status post tracheostomy for ventilator dependence. He had also developed subglottic stenosis from prolonged intubation. The patient was decannulated with grade 1 subglottic stenosis, and initially did well. However, over several months, the stoma remained fairly patent, prompting repeat direct laryngoscopy and bronchoscopy now demonstrating low grade 2 subglottic stenosis. The decision was made to proceed with laryngotracheal reconstruction with anterior rib cartilage graft, expanding the airway size from a 3.5 uncuffed endotracheal tube (ETT) to a 5.0 uncuffed ETT. The patient was transferred to the ICU and kept intubated and sedated until extubation on post-operative day 3. At 6 weeks postoperatively, direct laryngoscopy showed a well-mucosalized graft, with the airway still sized to a 5.0 ETT. Procedure details Direct laryngoscopy and bronchoscopy on the day of the reconstruction confirmed low grade 2 subglottic stenosis. The patient was intubated with a size 3.5 cuffed ETT for the procedure. Right rib cartilage harvest was performed after the endoscopic airway evaluation, followed by carving of the cartilage graft on the back table. The cartilage was carved into a modified tear drop shape to accommodate the tracheal stoma, with a length of 25mm and a width of 7mm. The intraluminal depth of the graft was sized to the bevel of a 15-blade. A fusiform incision was marked around the previous tracheostomy site. Scar tissue was dissected until the previous tracheostomy tract was clearly visualized and then excised. Once the patent tracheostomy was seen, the trachea and thyroid cartilage were skeletonized superiorly until the thyroid notch was reached. An incision site was marked from the superior aspect of the tracheostomy to the inferior border of the thyroid cartilage to avoid the anterior commissure. The marked incision site was then measured for confirmation of adequate sizing of graft, and confirmed to be 25 mm. A 15-blade was used to make the incision into the airway. An oral RAE tube was trimmed and placed at the inferior aspect of the tracheal incision, after the ETT was backed out, and ventilation continued through the modified oral RAE. The incision was then advanced into the inferior 2mm of the thyroid cartilage without performing laryngofissure, ensuring not to go through the anterior commissure. The patient was nasotracheally intubated with a 5.0 uncuffed ETT in preparation for graft placement, and the modified oral RAE was removed. The nasotracheal tube was advanced just beyond the graft site. The cartilage graft was placed using 4-0 Vicryl pop-off sutures on RB-1 needles in simple interrupted fashion. The sutures were first placed into the graft through the extraluminal side and coming out at the junction of the intraluminal depth and cartilage that would overlap the airway. Then the sutures were placed submucosally through the cartilaginous rings of the trachea, taking care to avoid entering the airway lumen to prevent granulation tissue. A total of 8-12 sutures are typically placed, left untied, and tagged. The graft was then parachuted into position, and all sutures tied to ensure knots are squared. The wound was filled with saline, and a Valsalva at 20cm H2O was performed to ensure there was no air leak. The strap muscles were then loosely closed, and a split Penrose drain was placed with one limb under the strap muscles and the other subcutaneously. The skin was closed in layered fashion with 4-0 Monocryl deep inverted interrupted sutures and 5-0 Monocryl in a running subcuticular manner. The patient was kept intubated and sedated for 3 days per protocol for anterior graft at our institution. Extubation was performed in the pediatric intensive care unit on post-operative day 3. A bronchoscopy was performed through the nasotracheal tube, and the patient was extubated over the bronchoscope. The graft site was visualized on the way out, and noted to be intact, mucosalizing, and without granulation tissue.and ensure it is intact. Humidified support was given via a nasal cannula following extubation. At 6 weeks postoperatively a direct laryngoscopy was performed, noting well-mucosalized graft, and airway still sized to a 5.0 uncuffed ETT. Indications/contraindications for single stage anterior cartilage graft reconstruction Indications Subglottic stenosis (SGS); high grade 1 to grade 2 SGS, failed decannulation for lower grade SGS, suprastomal collapse Proximal tracheal stenosis Other potential indications for rib cartilage grafting (with or without posterior grafting): Glottic stenosis Tracheal stenosis Vocal cord paralysis Laryngeal web Relative Contraindications Ventilator dependence Acute upper or lower respiratory tract infection Untreated concurrent airway obstruction (vocal cord paralysis, tracheomalacia, bronchopulmonary dysplasia, adenotonsillar hypertrophy, choanal atresia) Congestive heart failure (>30% oxygen requirements, weight < 1500g) Instrumentation Setup Patient placed supine with shoulder roll with head facing the anesthesia team. The neck and right anterior chest are prepped and draped in sterile fashion. If tracheostomy tube is present, modified cut down oral RAE, is sewn to chest wall opposite the planned cartilage donor site The anesthesia circuit is placed under sterile drapes in a manner to allow access by the anesthesia team during the procedure Preoperative workup Endoscopic examination of supraglottis, glottis, subglottis, trachea, and bronchi to confirm location of obstruction or stenosis and identify any other lesions or airway concerns. True vocal fold mobility is assessed and palpation of cricoarytenoid joint is performed to determine integrity of posterior glottis. Laryngopharyngeal reflux control may be considered prior to surgery. Discussion and communication with anesthesiologist before, during, and after the case to ensure smooth transitions between airways and during transport to the PICU. Weighted nasogastric feeding tube, if not already present, should be placed prior to beginning procedure, especially if posterior graft is planned. Anatomy and Landmarks Strap musculature Hyoid bone Thyroid cartilage Cricoid cartilage Proximal trachea Advantages Single stage procedure does not require decannulation at later date. Single stage allows for reconstructing the potentially weak area of the anterior tracheal wall at the trach site itself. Disadvantages For single stage procedure patients must be intubated and sedated in an intensive care unit for graft stenting for an adequate period of time. This requires sedation and occasionally paralysis, depending on the patient. Typically, the intubation is 3 days at our institution, but can be up to 5 for anterior grafting. Complications/risks Bleeding, infection, reaction to anesthesia, abnormal scarring, granulation, need for further procedures Graft dislodgement or failure Need for tracheostomy Pneumonia Pneumothorax Vocal cord injury if laryngofissure is performed

Nasopharyngeal Papillomatosis- A combined Transnasal Transoral Coblation Assisted Approach
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Title: Nasopharyngeal Papillomatosis- A combined trans nasal transoral coblation assisted approach Authors - 1. Dr Deepa Shivnani- corresponding author MBBS, DNB Otolaryngology , MNAMS, Fellowship in Pediatric Otolaryngology Children’s Airway & Swallowing Center Manipal Hospital, Bangalore , India email- deepa.shivnani14@gmail.com 2. Dr E V Raman MBBS, DLO , MS Otorhinolaryngology Children’s Airway & Swallowing Center Manipal Hospital, Bangalore Here I am presenting a case of 16 yrs old boy, who had nasal block and occasional cough. Nasal endoscopy revealed an exophytic papillomatous growth in the nasopharynx. MRI showed lesion arising from the nasopharyngeal surface of the soft palate. The lesion was free from the posterior pharyngeal wall. The patient was taken up for the procedure under general anaesthesia. The transoral approach was followed first. The tissue was taken for histopathological examination followed by a traction suture placed over uvula for better visualisation. Once exposed, coblation device was used transorally with 45 degree hopkins rod transorally. The tissue was ablated with coblation and coagulation settings of 9:5 respectively. The base was ablated too, to prevent further recurrence. Tonsillar pillar retractor was then used for better visualisation and exposure. The coblation was then continued. The tissue was removed transorally as much as possible then trans nasal approach was performed. Then, the same coblation device with the same setting was used but the nasal endoscope was changed to O degree Pediatric scope due to space constraints. The lesion was pushed upward with the help of yankaurs suction tip for better exposure and the remaining tissue was removed with the help of same coblation device. The lesion was excised completely and successfully with minimal blood loss. The operative area was confirmed with the 70Degree hopkins rod for complete removal of the lesion. Post operative recovery was uneventful. Combined transoral trans nasal coblation assisted approach is potential to be safer, easier and less invasive than uvulo palato pharyngoplasty in Pediatric age group specially, in the areas which are difficult to access like nasopharyngeal surface of the soft palate what we showed in this video.

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