This video shows a thyroid cyst removal that resulted in a hemithyroidectomy. The patient is placed under general anesthesia and intubated using a mac video laryngoscope and an EMG endotracheal tube. The ET tube has 4 stainless steel wire electrodes which touch the vocal cords for monitoring during surgery. After video intubation electrode placement is verified by direct stimulation of the area.
The surgeon makes a curvilinear skin crease incision in the front of the neck, to minimize the visibility of a scar. Afterwards, subplatysmal flaps are elevated and the midline raphe is dissected exposing the sternohyoid muscle, which is retracted laterally, and the sternothyroid muscle that is dissected off the left thyroid gland.
The thyroid cyst is found superficial and dissected, keeping in mind that anything suspicious for the recurrent laryngeal nerve is stimulated prior to dissection. The cyst is ruptured and sent for frozen pathology. The results returned as thyroid, so the surgeon proceeded with a hemithyroidectomy. The superior and inferior parathyroids were identified and dissected free. Hemostasis was achieved with electrocautery and confirmed with Valsalva. Strap musculature platysma and skin are closed. And lastly, mastisol and steri-strips are placed perpendicular to the wound.
Z-plasty allows broken-line closure, reorientation of the defect in the horizontal plane with re-creation of a cervicomental angle, and most importantly, a lengthening of the anterior neck skin that aids in preventing recurrent contracture. We present our experience managing a congenital cervical midline cleft in a 3-month-old patient and describe a simple technique for planning the ideal Z-plasty closure. No simple description for planning the ideal closure for this defect could be found in the otolaryngology literature.
Branchial cleft cysts are a benign anomaly caused by incomplete obliteration of a primordial branchial cleft. They typically appear in childhood or adolescence, but can appear at any age. They present as a non-tender, fluctuant mass following an upper respiratory infection, most commonly at the anterior border of the sternocleidomastoid muscle. These lesions are thought to originate during the 4th week of gestation when the branchial arches fail to fuse. The second branchial cleft is the most common site (95%) and cysts from in this distribution can affect cranial nerves VII, IX, and XII.
In this video, we present a new method of tension-free thyroidectomy (TFT). The procedure is based on the medial approach to the recurrent laryngeal nerve and the parathyroid glands after the division of isthmus and successive complete dissection of Berry’s ligament. The operation was performed under general anesthesia with endotracheal intubation. Patients were placed in a supine position without neck extension. A 35-40 mm horizontal skin incision was made 1 cm above the sternal notch. Subcutaneous fat and platysma muscle were dissected. The linea alba was incised longitudinally for 4–5 cm. When the isthmus capsule was exposed, the last was divided in the middle. Full mobilization of the isthmus and thyroid lobe from the trachea by dissecting the Berry’s ligament was performed. Intermitted neuromonitoring (5 mA, Inomed C2) was used to guide the division of fibers of the Berry’s ligament. By using the pinnate the thyroid lobe was retracted into the lateral direction (only lateral traction of the thyroid lobe was used during the operation). The mobilization of the thyroid lobe from the trachea was completed by the division of small branches of the inferior thyroid artery and vein. The main branch of the inferior thyroid artery and vein were preserved along with the vessels supplying the parathyroid glands. After complete separation of the thyroid lobe and inferior thyroid vessels from the trachea the recurrent laryngeal nerve was identified and dissected. Also from the medial side, the upper and lower parathyroid glands and their vessels were identified and fully separated from the thyroid capsule. The lower pole of the lobe was pulled out of the thyroid bed. Finally, after neuromonitoring of the superior laryngeal nerve, the upper pole vessels were dissected and divided. In case a total thyroidectomy the same procedure was performed on the contralateral side after vagus stimulation (V2).
This video highlights the surgical nuances of rectus abdominis myocutaneous free flap harvest.
Authors: Yonatan Lahav, MD, Doron Halperin, MD, Hagit Shoffel-Havakuk, MD.
Subepithelial vocal fold cordectomy (Type I cordectomy according to the ELS classification) for Carcinoma In Situ, performed under general anesthesia with direct microlaryngoscopy and suspension using a free beam CO2 Laser. The resection respects the layered structure of the vocal folds and preserves the superficial lamina propria and its vasculature. The video follows the procedure step by step and includes detailed instructions.
Contributors: Raj Dedhia, M.D
Eagle’s Syndrome, also known as Styloid Syndrome, is defined by the presence of an elongated, misshapen, or calcified stylohyoid ligament. It is characterized by pain localized to either side of the throat, odynophagia, and referred otalgia. Transoral removal of the stylohyoid ligament consists of transecting the stylohyoid ligament to release tension and result in improvement of pain.
DOI #: https://doi.org/10.17797/o3iz10qacz
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.
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.
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.
Macrocystic lymphatic malformations are amenable to surgical resection at low risk and without recurrence.
By: Ravi W Sun, BE
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
Contributors: Umamaheswar Duvvuri
An 18-year-old African American female with a large, type II branchial cleft cyst and a history of keloid scars presented for removal of branchial cleft cyst. We present the first robotic-assisted excision of branchial cleft cyst using the new Flex Robotic© Surgery System.
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.