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

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

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.

Lingual Tonsillectomy with Epiglottopexy

Posterior displacement of the epiglottis secondary to lingual tonsil hypertrophy is a common cause for persistent obstructive obstructive sleep apnea after adenotonsillectomy in the pediatric population. By use of an operating micorscope an endoscpoic technique for lingual tonsillectomy and a epiglottopexy is described.

Total Tonsillectomy

Total Tonsillectomy Sarah Maurrasse MD, Vikash Modi MD Weill Cornell Medicine, Department of Otolaryngology Tonsillectomy is one of the most common surgical procedures performed in children. The two main indications for tonsillectomy are sleep disordered breathing and recurrent infections, both of which are common in the pediatric population. This video includes 1) a detailed introduction including relevant anatomy 2) a discussion of the indications for total tonsillectomy 3) surgical videos and diagrams to explain the steps of the surgical procedure and 4) an explanation of possible post-operative complications.

Partial Tonsillectomy

Partial Tonsillectomy Sarah Maurrasse MD, Vikash Modi MD Weill Cornell Medicine, Department of Otolaryngology Tonsillectomy is one of the most common surgical procedures performed in children. The main indication for partial tonsillectomy is sleep disordered breathing, which includes a spectrum of disorders from primary snoring to obstructive sleep apnea (OSA). This video includes 1) figures of the anatomy relevant to partial tonsillectomy 2) a discussion of the indications for partial tonsillectomy and 3) surgical videos and diagrams that explain the steps of the surgical procedure.

Endoscopic Repair of Type IIIB Posterior Laryngeal Cleft

We present a case of a type IIIB posterior laryngeal cleft treated successfully with endoscopic repair.

Transoral incision and drainage of retropharyngeal abscess.

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.

IPAS 2022: Laryngeal Cleft: Workup & Repair

9 AM EST / 7:30 PM IST

Moderator: Vikash Modi

Panelists: Hamdy El-Hakim, Jen Lavin, Shyan Vijayasekaran, Bas Pullens

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Pediatric Endoscopic Airway Surgery

This webinar will address common and advanced pediatric airway pathology. There will be a focus on video demonstration of advanced surgical endoscopic management of pediatric airway pathology ranging from laryngomalacia to type 3 laryngeal clefts.

Vikash K. Modi, MD, is an Associate Professor and the Chief of Pediatric Otolaryngology - Head & Neck Surgery at New York Presbyterian Hospital- Weill Cornell Medical Center. After receiving his medical degree from the Rutgers Medical School, Dr. Modi completed his residency in Otolaryngology at the University of Southern California - Keck School of Medicine. Following residency, Dr. Modi completed a Pediatric Otolaryngology fellowship at Northwestern University - Children's Memorial Hospital. He founded the Cornell Aerodigestive Center and has one of the largest series of endoscopic posterior cricoid split with rib grafting (presented at ESPO). He also has presented his work on endoscopic repair of laryngeal clefts at ASPO and CEORL. He has been inducted as a Fellow, into the prestigious Triological Society for his thesis paper on airway balloon dilation and currently serves as a Section Editor-Video Editor of The Laryngoscope and is known for his surgical endoscopic airway videos.

Laryngeal Clefts

Drs. Vikash Modi, Hamdy El Hakim, & Christina Rappazzo talk about the different challenges facing surgeons dealing with laryngeal clefts. They review how to properly assess and manage the situation and even go into some controversies between different styles.

Pearls from the COVID Trenches

Join this interactive webinar with Dr. Sanjay Parikh (Seattle Children’s), Dr. Natalie Loundon (Hopital Necker-Enfants Malades, Paris), Mr. Michael Kuo (Consultant and Clinical Lead, Birmingham Children’s, UK), Dr. Vikash Modi (Chief of Pediatric ENT, New York Presbyterian Hospital), along with Dr. Shyan Vijayasekaran (Perth ENT) and Dr. Scott Rickert, (NYU Langone) as they discuss their learnings from being on the front lines of COVID area hotspots.

The panel will discuss testing, PPE, as well as lessons learned.

This webinar is in follow up to a previous presentation by Dr. Vijayasekeran and Dr. Rickert from April 10th. To access the recording of the previous webinar please go to www.csurgeries.com