Velopharyngeal insufficiency (VPI) is a speech disorder characterized by inability for the palate (velum) to contact the posterior pharyngeal wall resulting in nasal air escape and subsequent speech abnormalities. All but the mildest cases are treated surgically, with technique chosen based on the closure pattern and gap size reserving the pharyngeal flap for the most severely affected patients. We present a 6-year old female with developmental delay and VPI with large (~60%) coronal pattern velopharyngeal gap subsequently deemed a candidate for posterior pharyngeal flap.
Following Dingman mouthgag placement, the posterior wall is inspected and palpated ensuring no carotid medialization. The flap is designed and marked as wide and long as possible to reduce tension. Local injection wis performed. Using an angled needle tip Bovie, the flap was then elevated in the plane the prevertebral fascia to the level of the nasopharynx. The donor site is closed with simple interrupted 4.0 chromic sutures. The palatal mucosa is divided in a T-shaped fashion, without violating palatal musculature. The flap is inset with horizontal mattress sutures using 4.0 chromic. The nasal ports are inspected frequently to ensure adequate nasal airway patency. The palatal mucosa is reapproximated and any residual donor site closed. The patient is observed overnight, discharged home post-operative day 1, maintained on a soft diet for two weeks and abstains from speech therapy for 4 weeks to allow healing. Follow up demonstrated excellent healing well and VPI resolution on repeat speech sample.
Abstract
Introduction: Arteriovenous malformations (AVMs) are abnormal connections between arteries and veins that lack an intervening capillary network. The high flow of arterial blood directly into veins can lead to the weakening of venous walls, potentially resulting in life-threatening hemorrhages.The primary treatment modalities for cerebral arteriovenous malformations (AVMs) include surgical resection, endovascular embolization.
Case presentation: A 34-year-old female presented with a roughly 7×7 cm arteriovenous malformation (AVM) located in the right temporoparietal area. The AVM extended both superficially and deeply into the infratemporal fossa and laterally towards the orbit. Imaging revealed the presence of multiple large contributing vessels in the preauricular area. The patient underwent embolization with interventional radiology one day prior to the surgical procedure.
Methods: Markings were made along the right upper hairline after trimming and continued down the preauricular skin. A #15 blade was utilized to make incisions through the epidermis and dermis, reaching the subcutaneous tissues. The temporoparietal and temporal flap fascia were dissected and carefully raised. Once the AVM was detached from the surrounding temporalis muscle and the zygomatic bone, its feeder vessels were ligated near the tragal pointer using hemoclips to aid in future localization. Hemostasis was successfully achieved with bipolar cautery. The temporalis muscle and its adjacent fascia were sutured closed with vicryl suture. Closure of the deep dermal layer was accomplished with 4-0 PDS, and the skin was closed in a running subcutaneous fashion using 5-0 monocryl.
Conclusion : We present a successful surgical resection of Arteriovenous Malformation with a prior embolization by interventional radiologist
Surgeons:
Coleman, Madison, MD,
Aryan D Shay ,MD
Gresham T Richter, MD, FACS
Conflicts of Interest: None
Funding: This research received no external funding
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
This video presents a case of a large hard palate fistula, which was repaired with an anterior tongue flap. The details of the procedure are described and demonstrated in detail, including both stages of the reconstruction, which were timed 3-4 weeks apart.
Stage 1 Microtia Repair using rib cartilage and modifications to the Nagata method of auricular formation.
DOI#: http://dx.doi.org/10.17797/cquv22l7p3
Contributors: Shira Koss
6 year old boy suffering from bullying at school as a result of bilateral cryptotia, a very unusual congenital ear anomaly in which the superior helix is buried under temporal skin.
DOI#: http://dx.doi.org/10.17797/le4g6c5rk5
Contributors: Raj Dedhia, M.D
Obstructive sleep apnea is a common disorder with many possible etiologies. Surgical therapy is aimed at reducing or eliminating an area of airway stenosis that predisposes patients to obstructive sleep apnea. Expansion sphincter pharyngoplasty consists of transecting the palatopharyngeus and reinserting it into the lateral soft palate and periosteum of the pterygoid hamulus to widen the pharyngeal airway.
DOI #: https://doi.org/10.17797/i9jgkva8m4
This is the second stage of Microtia Reconstruction, the first stage was depicted in a prior video. The ear is elevated and lateralized to take its 3-dimensional form, and this is accomplished with use of an anteriorly based mastoid fascial flap as well as costal cartilage graft and full thickness skin graft.
Editor Recruited By: Michael Golinko, MD
This procedure is a total calvarial vault expansion to correct pansynostosis in a three-year-old child. Total calvarial reconstruction is an open procedure that consists of removing bone flaps with an osteotome, outfracturing the skull bone edges with a rongeur to allow for future expansion, shaving down the bone flap inner table with a Hudson brace to create a bone mush for packing the interosseus spaces, and modifying then reattaching the bone flaps with absorbable plates and screws. This patient is status post craniofacial reconstruction for earlier sagittal synostosis. Second operations are uncommon after correction of single-suture synostosis, so this more aggressive technique represents an attempt to definitively correct the calvarial deformity and resolve the signs and symptoms of the attendant intracranial hypertension. Indications for surgery include cosmetic and neurologic concerns, here including a Chiari malformation and cervicothoracic syrinx. This educational video is related to a current research project of the Children’s National Medical Center Division of Neurosurgery regarding single-suture craniosynostosis and the factors that place children at risk for surgical recidivism in the setting of intracranial hypertension.
Kelsey Cobourn, BS – Children’s National Medical Center Division of Neurosurgery and Georgetown University
Owen Ayers – Children’s National Medical Center Division of Neurosurgery and Princeton University
Deki Tsering, MS – Children’s National Medical Center Division of Neurosurgery
Gary Rogers, MD, JD, MBA, MPH – Children’s National Medical Center Division of Plastic and Reconstructive Surgery and George Washington University School of Medicine
Robert Keating, MD – Children’s National Medical Center Division of Neurosurgery and George Washington University School of Medicine (corresponding author)
The retropalatal airway is a common site of collapse in obstructive sleep apnea. Transpalatal advancement pharyngoplasty aims to address this site of upper airway collapse by advancing the soft palate anteriorly, increasing the cross-sectional area of the airway and decreasing pharyngeal collapsibility.
Surgeon: Raj C. Dedhia1, MD, MSCR
Video Production: Yifan Liu1,2, MD, Jason Yu1, MD
1 Perelman School of Medicine, Department of Otorhinolaryngology–Head and Neck Surgery, University of Pennsylvania
2 Department of Otorhinolaryngology – Head and Neck, Affiliated Beijing Anzhen Hospital, Capital Medical University
Congenital aural atresia (CAA) is a birth defect that describes both aplasia and hypoplasia or stenosis of the external auditory canal (EAC). CAA can be associated with microtia (malformation of the pinna), middle ear and occasionally inner ear malformations. Surgical correction of CAA is a very challenging operation and requires a thorough knowledge of the surgical anatomy of the facial nerve, middle and inner ears. Traditional post-auricular approach or transcanal approach with the help of a microscope usually provides adequate images needed for the procedure. Endosocpic ear surgery provides the advantage of visualization beyond the view provided by the microscope, further refinement of the surgical approach, precise assessment of the ossicular chain mobility and placement of ossicular chain prosthesis if necessary.
