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: 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
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
Contributors: Jeffery Scott Magnuson (University of Central Florida) 1) Purpose: The patient had a history of biopsy proven squamous cell carcinoma of the right palatine tonsil and elected for surgical resection as a primary treatment. 2) Instruments: The DaVinci surgical robot was used with the Maryland dissector and a monopolar cautery on the arms. The FK retractor was used to suspend the patient and gain exposure. 3) Landmarks: The right palatine tonsil is resected along with a cuff of pharyngeal musculature. 4) Procedure: In sequence, the initial incision on the anterior tonsillar pillar, the exposure of the parapharyngeal space, the removal of the specimen, and the final defect are shown. 5) Conflicts of interest: for JSM: Intuitive Surgical: Instructor/Proctor, Honoraria; Lumenis: Consultant, Honoraria; Medrobotics: Member Strategic Advisory Panel, Honoraria. 6) References: Chung, T. K., Rosenthal, E. L., Magnuson, J. S. and Carroll, W. R. (2014), Transoral robotic surgery for oropharyngeal and tongue cancer in the United States. The Laryngoscope. http://dx.doi.org/10.1002/lary.24870 DOI: http://dx.doi.org/10.17797/kjwgjsgxwk
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: Soham Roy and Steven Curry Adenoidectomy is among the most common surgical procedures performed in children. The two major indications are nasopharyngeal airway obstruction and recurrent or chronic infections of the nasopharynx. This surgery is often carried out with a combined tonsillectomy which is performed for similar indications and depicted here.
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.
Contributors: Dr. James Hamilton Intracapsular tonsillectomy using the microdebrider is demonstrated here in a child with obstructive sleep apnea.
Adenoidectomy is among the most common surgical procedures performed in children. The two major indications are nasopharyngeal airway obstruction and recurrent or chronic infections of the nasopharynx. This surgery is often carried out with a combined tonsillectomy which is performed for similar indications. The technique used in this video is suction electrocautery, a recently developed technique that allows for more precision and minimal blood loss compared with more traditional techniques. Soham Roy (University of Texas Medical School at Houston) Thomas Mitchell (University of Texas Medical School at Houston)
Tonsillectomy is among the most common surgical procedures performed in children. The two major indications are oropharyngeal airway obstruction and recurrent or chronic infections of the oropharynx. In this video, radiofrequency ablation, or Coblation (controlled ablation), is the technique used to ablate the tonsils. This technique uses low-temperature radiofrequency and saline to create a plasma field that dissolves tissue. It is generally safer that high-temperature electrocautery and allows for precise removal of tissue without burning nearby structures. Contributors: Soham Roy (University of Texas at Houston Medical School) Thomas Mitchell (University of Texas at Houston Medical School) Steven Curry (University of Texas at Houston Medical School)
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 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.
Tonsillectomy is one of the most common surgeries performed today, yet debate continues regarding the best technique to avoid complications. We’ll review one method in this video, snare tonsillectomy, which is a "cold" technique. We'll discuss it's advantages over other methods, and a step-by-step instructional video.
A 52-year-old female presented for an evaluation for sleep apnea surgery. She complained of choking sensation at night. She had an AHI of 6.7 events per hour, a oxygen saturation nadir of 71%, and BMI of 30.6. She and a prior history of adenotonsillectomy as a child. Flexible examination in the office revealed grade 4 lingual tonsil hypertrophy. She was deemed a candidate for lingual tonsillectomy and was taken to the operating for robotic lingual tonsillectomy. The technique for adult lingual tonsillectomy is shown in step-by-step fashion with tips for good results both operatively and functionally learned from robotic surgery for cancer of the unknown primary origin. Contributors: Jessica Moskovitz, MD, Leila J. Mady, MD, PhD, MPH, Umamaheswar Duvvuri, MD, PhD
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.
This time last year I was sitting in a classroom at the school of education, learning about metacognition, reflection, and deep understanding. It had only been 18 short years since I graduated high school and I couldn’t help but wonder – How did I get here? I had finished my ear, nose, and throat (ENT) surgical training and quickly went from learning about resecting cancer and performing airway reconstruction to learning about teaching for understanding.
Over the previous 6 months I went from reading books from ENT legendaries like Dr. Charles Cummings and Dr. Jonas Johnson, to readings by education legendaries Edward Thorndike, Jean Piaget, Howard Gardner, and Carol Dweck. I asked myself, what am I doing here and why do I keep pursuing more graduate education?
I realized that I was in this classroom to learn about learning and somehow parlay it into improving my own teaching, and hopefully, that of those around me. I felt somewhat disenfranchised with the state of surgical education today. Advances in the cognitive theory of learning were spreading like wildfire through K-12 and secondary education that, traditionally, have been missing in medical training. As I sat there, I contemplated ways to adapt the lessons learned and bring cognitive theory to surgical education.
I preface this all with the fact that many of my instructors along my educational journey are excellent teachers, as are many people reading this post. I also realize that everyone is a teacher and a learner everyday in their lives; whether to patients, friends, relatives, or peers, everyone teaches someone something sometime. My goal with this post is to deconstruct our own teaching experiences and to connect them to underlying cognitive learning principles, so that we may adapt and magnify them to make ourselves more efficient and efficacious educators.
Novice-Expert Shift, Zone of Proximal Development (ZPD), and Desirable Difficulty
Theory: The novice-expert shift is the journey our trainees take as they go from not knowing what they don’t know (true novice) to becoming experts in their field. During this journey, they follow a path that is domain-specific and different for every student. For example, they may develop laparoscopic skills much more swiftly than soft tissue skills, or vice versa. The importance of this in surgical education is that no student’s growth in every domain will follow a straight line corresponding to his or her year in training. [See Pusic et al. for more on learning curves in health professions education]. This is the principle behind competencies and milestones rapidly making their way into medical education. Despite the recent implementation of these principles, I still hear attending surgeons say, “I never let a third year resident insert a cochlear implant or let 2nd year residents do X”. I still see colleagues lecturing students with the same talk they gave at conferences in years past without ascertaining where their level of understanding of their audience or leveraging their base knowledge on the subject.
The Zone of Proximal Development (ZPD) essentially lies on either side of the student growth curve and delineates the boundaries of tasks that will result in positive student learning [See Vygotsky (1978) for more on ZPD or DiSessa (2000) on Regime of Competence]. Tasks too far below this zone are too simple and will not result in moving students much along their growth curve. Too far above and the task is too difficult to complete, leading to learner frustration and stagnation. The sweet spot, or what I call the Goldilocks zone, is where the student will be maximally challenged and advance furthest along their learning continuum. If you target the zone above the curve, for both cognitive and practical skills, you will maximize their growth.
Application to Practice: In my teaching, I try to remain agnostic to residents’ training year and gauge their skill in each domain based on their own insight into their abilities, and what they demonstrate in the operating room. Intuitively, we all probably give trainees graduated responsibilities that will stretch their capabilities. I try to take this further and ask every individual trainee, before a case, where they are along their continuum of learning for that particular case and where they want to be after. This requires the instructor to meet with the resident before the case or before the day starts to assess their base knowledge or skill. Often, due to time constraints, this isn’t practical but, again, if we want to be the most efficient at teaching our residents we need to keep these concepts in mind. During the case I give them more and more difficult tasks in a sort of game to figure out where the limit of their zone is and we stay right at that level until the case is over. I then ask them three simple questions after each case: “What could I have done better as an instructor? What are areas you would like to improve on as a surgeon? What could have everyone done better as a team?” I try to engage the OR staff and anesthesiology team in the last question as often our cases employ the shared airway principle between our two teams. This reflection and metacognition on our experience is another principle that we will cover another time, but is vital to their learning. Here is where, as the expert, we can assess their insight and get a gauge of their progression on their learning continuum.
Implicit knowledge to Explicit knowledge, Context, and Schema Formation
Theory: When I get a first-year medical student in my clinic in OR, it is extremely difficult, dare I say impossible, to imagine what it was like to be at that level. One major barrier is that as an expert, you have highly refined and streamlined information storage in your head, and have automatized many cognitive tasks. This organizational strategy or ‘schema’ is very individualized and content-specific. In deciding which bookshelf to store information in your head, you have made it the most efficient for retrieval when needed and attached to other similar nuggets of information. Along with this, as an expert, you have cleared space on the shelves by pushing out elements of information that are no longer needed because they are implicit. You no longer need to remember that the right pedal makes the car go forward and the left one makes the car slow down. These assumptions and automations you have introduced into practice are very difficult to unpack for the novice learner. Imagine explaining how to drive to the grocery store to someone who has never driven a car before. As a teacher it is very difficult to unpack every little important detail needed and make them explicit for the learner. Master teachers are able to take their schema for a particular topic, fully deconstruct it into its component parts and transfer that knowledge in a sensible fashion to their students.
Application to Practice: I try to imagine myself trying to learn something for the first time. Last year I learned the basics of how to write code for websites. I realized that a major barrier to learning anything was that you had to get the basic words that people use and understand the context in which they are used. I had to start out by understanding what ‘h1’ meant and why it mattered. James Paul Gee in his book What Video Games Have to Teach Us About Learning and Literacy discusses ‘situated cognition’ and ‘situated meaning.’ He explains that words are context- and domain specific and uses the term ‘work’ as an example. This word means something totally different to human resources versus a physics professor. We must think about the efficacy of the message if the true novice doesn’t know the words or context, especially in the context of surgery, the operating room, or even medicine. This is the same principle we must remember when explaining surgery to our patients or families.
As I go through the surgery I try to unpack things in my own head before describing it piecemeal to the trainee. I encourage the resident to call me out when I skip over something or they feel I made an assumption. Residents often feel apprehensive to point out weak knowledge areas so it is essential I set up a safe learning environment. This is also exemplified during our post procedure feedback session where we undergo a frank discussion of what went well, what needs work and how to proceed.
Cognitive Load and Chunking
Theory: Cognitive load is familiar to most. It is essentially the mental capacity of someone to absorb information in a given learning experience. This is traditionally split into intrinsic, extrinsic, and germane load. These loosely can be seen as the complexity of the learning content itself, the complexity of how the content is delivered, and the mental energy needed to internalize the information. Chunking is one technique to lower the intrinsic cognitive load by only including smaller, digestible pieces of information. The cognitive load of any learning experience, cognitive or procedural, can be managed this way.
Application to Practice: My attending in fellowship, David Roberson, had a great way to put this into practice. When he taught tonsillectomy, he would do the first 90% of the surgery and then allow the trainee to finish the surgery. The next time he would do 60% and so on until the resident was doing the whole case. Without him knowing, he was chunking the information and managing the cognitive load so residents could focus on the task at hand. It was also backwards design in some sense as the resident saw what the finished product looked like and could just focus on getting to the next point in the case. They also focused on the easiest part of the case first and repeated completing the case a multitude of times instead of messing with putting the mouth gag in, initially grasping the tonsil, and finding the capsule (often the harder parts of the procedure). When I start cases with residents I think about what they want to focus on so I can manage the cognitive load and move them along their learning curve and not dwell on things they have already mastered.
Over the last year and a half I have come to realize that the cognitive psychology of learning is not as scary as I had originally thought. It underpins what many of us know as good teaching strategies. I realize for many of us bringing theory to practice can seem overwhelming. I found that starting with just one strategy, i.e. managing my own cognitive load, made a huge impact on my teaching. Over time I have instituted many other cognitive principles and continue to look for ways to incorporate them into my every day teaching of students, residents, and fellows. Which of these principles do you intend to include in your practice? Comment on the blog to share specific strategies with our community!
Have a question you would like to ask Dr. Gantwerker? Feel free to post a comment or send him an email at Eric.Gantwerker@csurgeries.com
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