Simultaneous Translabyrinthine Vestibular Schwannoma removal and Cochlear implantation in small tumor using CI632 device
Specialty: Otolaryngology
Cartilage Tympanoplasty: Graft Placement
Introduction: Cartilage tympanoplasty is a surgical procedure aimed at repairing the tympanic membrane using cartilage grafts. This technique is particularly effective in cases of chronic otitis media, recurrent perforations, where traditional methods may fail. The procedure not only aims to close the perforation but also to restore hearing and reconstruct a healthy middle ear cavity. This case report presents a patient undergoing cartilage tympanoplasty placement procedure, highlighting the surgical technique.
Procedure Presentation: The cartilage tympanoplasty procedure begins with harvesting tragal cartilage, carefully preserving an anterior remnant for cosmetic purposes. The graft is measured, harvested, and trimmed to fit the tympanic membrane defect, with the perichondrium preserved on one side. A central trough is carved for seating on the malleus handle. The tympanomeatal flap is elevated, allowing placement of the graft in the middle ear cavity medial to the tympanic membrane. Crushed gel foam supports the graft, and the tympanomeatal flap is draped over it. The surgeon carefully inspects to ensure proper placement and complete perforation coverage. Additional gel foam in the canal prevents graft lateralization, completing this precise and meticulous surgical technique.
Conclusion : This case report demonstrates the effectiveness of cartilage tympanoplasty in treating chronic otitis media with tympanic membrane perforation. The use of cartilage grafts provides a robust and reliable method for tympanic membrane reconstruction, offering excellent anatomical and audiological outcomes. Further studies with larger patient cohorts are recommended to validate these findings and refine the surgical technique.
Cartilage Tympanoplasty: Graft Harvest and Formation
Introduction: Cartilage tympanoplasty is a surgical procedure aimed at repairing the tympanic membrane using cartilage grafts. This technique is particularly effective in cases of chronic otitis media, recurrent perforations, where traditional methods may fail. The procedure not only aims to close the perforation but also to restore hearing and reconstruct a healthy middle ear cavity. This case report presents a patient undergoing cartilage tympanoplasty placement procedure, highlighting the surgical technique.
Procedure Presentation: The cartilage tympanoplasty procedure begins with harvesting tragal cartilage, carefully preserving an anterior remnant for cosmetic purposes. The graft is measured, harvested, and trimmed to fit the tympanic membrane defect, with the perichondrium preserved on one side. A central trough is carved for seating on the malleus handle. The tympanomeatal flap is elevated, allowing placement of the graft in the middle ear cavity medial to the tympanic membrane. Crushed gel foam supports the graft, and the tympanomeatal flap is draped over it. The surgeon carefully inspects to ensure proper placement and complete perforation coverage. Additional gel foam in the canal prevents graft lateralization, completing this precise and meticulous surgical technique.
Conclusion : This case report demonstrates the effectiveness of cartilage tympanoplasty in treating chronic otitis media with tympanic membrane perforation. The use of cartilage grafts provides a robust and reliable method for tympanic membrane reconstruction, offering excellent anatomical and audiological outcomes. Further studies with larger patient cohorts are recommended to validate these findings and refine the surgical technique.
Pediatric Endoscopic Butterfly Inlay Tympanoplasty
Educational/Technical Point(s): Endoscopic butterfly inlay tympanoplasty is a reliable and useful technique in select pediatric patients. This technique prevents the need for flap elevation, intratympanic myringosclerosis excision that could result in significantly larger perforation, or malleus dissection which can result in permanent hearing reduction. The procedure has a shorter operative time than traditional techniques and excellent results in pediatric patients.
Introduction:
Butterfly inlay tympanoplasty is a more recently described but validated technique for repairing select tympanic membrane perforations.1 Following its validation in adult patients, small series have demonstrated its successful use in the pediatric population as well, including via endoscopic approach. 2 Despite these findings, the indications for when to use this repair technique remain nebulous. We discuss our institution’s approach to the use of this technique and factors that influence its implementation through a case presentation.
Case Presentation:
We present a 14-year-old female with a history of long standing anterior tympanic membrane perforation. She was seen in consultation at our quaternary children’s hospital with a remote history of ear tube placement, subsequent extrusion, and ongoing perforation. Audiometry revealed a moderate conductive hearing loss and large volume type B tympanogram. Examination demonstrated an ~30% anterior central clean dry perforation. Her perforation was anterior to the handle of the malleus and demonstrated a significant intratympanic myringosclerotic plaque adjacent to the perforation. Given the location, and adjacent plaque whose removal would have resulted in nearly the double the size of the perforation, endoscopic butterfly inlay technique was recommended.
Technique:
The patient was brought to the operating room and injected and prepped in standard fashion including injection of local anesthesia to the donor tragal site. The perforation was rimmed using a Rosen needle and the subsequent tissue removed with cup forceps. Following recipient site preparation, the perforation was measured using a standard right angle hook whose length is 3 mm demonstrating a 4 mm by 3 mm perforation.
Attention was turned to harvesting a tragal graft in standard fashion. Using a 5 mm dermal punch, a full thickness portion of the cartilage was obtained ex vivo and the residual cartilage was replaced into the donor site for any future needs and the wound closed in simple interrupted fashion. The cartilage was scored circumferentially with a 15 blade creating locking flanges for the graft. The graft was then placed via alligator. The graft was purposefully placed through the perforation into the middle ear cleft, and then retracted by its perichondrium into the perforation, essentially “locking” it into place. Additional flange adjustments were made using a Rosen needle to ensure the graft was seated, appropriately. The tympanic membrane was coated with bacitracin and the patient was awoken from anesthesia.
Standard post operative tympanoplasty care was recommended including dry ear precautions and avoidance of heavy physically exercise until her post operative follow up. At follow up, she demonstrated 100% graft take and resolution of her prior hearing loss with a mobile tympanic membrane.
Conclusion:
Endoscopic butterfly inlay tympanoplasty is a reliable and useful technique in select pediatric patients. This technique prevents the need for flap elevation, intratympanic myringosclerosis excision that could result in significantly larger perforation, or malleus dissection which can result in permanent hearing reduction. The procedure has a shorter operative time than traditional techniques and excellent results in pediatric patients.
Right Neck Dissection
Introduction
Neck dissection stands as a crucial surgical procedure predominantly utilized in addressing head and neck cancers. It involves the methodical elimination of lymph nodes and potentially adjacent tissues to curb cancer dissemination. This procedure can be delineated into several types based on the extent of surgery and the structures targeted, including radical neck dissection (RND), modified radical neck dissection (MRND), selective neck dissection (SND), and extended neck dissection.[1]
Neck dissection is recommended for various conditions such as metastatic neck cancer, cancers affecting the oral cavity, pharynx, larynx, or thyroid with a high risk of lymphatic spread, and as a prophylactic measure in cases of head and neck cancers with a high risk of occult metastasis.[1] Understanding the anatomy of the cervical lymphatic system, which is divided into distinct levels (I-VII) each containing specific groups of lymph nodes, is essential for conducting effective neck dissection.[2,3] The radical neck dissection (RND), introduced by George Crile Sr. in 1906, was long regarded as the standard treatment for metastatic neck disease.[2,4] However, modifications to the procedure have been developed over time to reduce associated morbidity while ensuring oncological safety.[1]
Surgical procedure
The surgical procedure of neck dissection typically involves a series of steps: an incision is made along an existing neck crease, subplatysmal flaps are then elevated to expose underlying anatomical structures and lymph nodes, different groups of lymph nodes are systematically removed depending on the type of dissection, and finally, the surgical site is closed in layers with the placement of a drain.[4] Complications of neck dissection may include nerve damage resulting in shoulder dysfunction, bleeding and hematoma formation, infection and issues with wound healing, as well as the development of lymphedema.[1]
Conclusion
Neck dissection is a vital procedure in the management of head and neck cancers, designed to remove lymph nodes that may harbor metastatic disease. The type of neck dissection performed is tailored to the extent of disease and the need to preserve function and reduce morbidity. A thorough understanding of the anatomy and careful surgical technique are essential to optimize outcomes and minimize complications.
References
Harish K. Neck dissections: radical to conservative. World J Surg Oncol. 2005 Apr 18;3(1):21. doi: 10.1186/1477-7819-3-21. PMID: 15836786; PMCID: PMC1097761.
Jiang, Z., Wu, C., Hu, S. et al. Research on neck dissection for oral squamous-cell carcinoma: a bibliometric analysis. Int J Oral Sci 13, 13 (2021). https://doi.org/10.1038/s41368-021-00117-5
Rigual NR, Wiseman SM. Neck dissection: current concepts and future directions. Surg Oncol Clin N Am. 2004;13(1):151-166. doi:10.1016/S1055-3207(03)00119-4
Antonio Riera March, M. (2023, November 28). Radical neck dissection. Background, History of the Procedure, Problem. https://emedicine.medscape.com/article/849895-overview?form=fpf
Endoscopic Perctaneous Suture Laterlization for Neonatal BVFP
This video provides an elucidation of the surgical steps involved in performing an endoscopic perctaneous suture laterlization in a neonate with bilateral vocal fold paralysis.
4 Gland Duct Ligation
Four Gland Duct Ligation with Botulinum Injections
Background:
This video visualizes the four-duct ligation surgery for chronic sialorrhea. Sialorrhea is characterized by the improper spilling of saliva, most commonly due to poor muscle coordination1. Controlling oral secretions with the perioral muscles and the act of swallowing takes precise contraction from voluntary and reflex contractions. Sialorrhea is common in newborns and children up to 5 since they have not learned to coordinate these contractions yet1. The most common etiology of persistent, or new, sialorrhea is cerebral palsy, amyotrophic lateral sclerosis, seizures, cerebrovascular accidents, facial paralysis, and dental problems1.While many neurological conditions can predispose a child to sialorrhea, cerebral palsy is most common, comprising up to 10% of cases3.The side effects of untreated sialorrhea include increased risk of infections, dental caries, and interference with speech. Aspiration pneumonia is a serious consequence from pooling of saliva in the posterior pharynx3. Patients can also become malnourished due to trouble chewing, loss of fluids/electrolytes, and loss of protein2. Non-evasive measures such as oral motor therapy, behavior modification therapy via biofeedback, and drug therapy should be considered before proceeding to surgical treatment2. Surgical treatment is preferred when the patient is at risk for aspiration pneumonia3. One of the most common surgical procedures for sialorrhea is the four-gland duct ligation. While the four-gland duct ligation is low risk for complications, facial swelling, aspiration pneumonia, oxygen desaturation, and vomiting are potential complications. Out of these, facial swelling was the most common adverse event3.
Methods:
An appropriate surgical candidate was identified in the clinic and advised about the risks and benefits of the procedure. The patient was appropriately prepped and inducted under general anesthesia. An oral side bitter was placed to visualize the oral cavity. Stensen’s duct was identified on the left with army navy retraction. A lacrimal probe was used to maintain the duct opening and an alice retractor was used to hold the duct in place. The dissection was performed bluntly and with cautery. Care was taken to prevent injury to the duct and to provide clear exposure. The probe was removed, and the proximal portion of the duct was ligated with two oppositely placed 3.0 silk sutures. The mucosa was then closed with 4.0 chromic suture in a simple interrupted stitch. The same procedure was performed on the contralateral side. The focus was then turned to whartons duct. The oral side bitter was removed, and the tongue was retracted using an army navy. The right papilla was identified and retracted with a Geralds with teeth to maintain proper visualization of the duct. Blunt and cautery dissection was performed around the duct for proper exposure. Once down to the base of the duct, tonsil clamps were used to clamp just proximal to the gland to aid with suture ligation. Two oppositely placed 3.0 silk sutures were used to ligate the duct. The mucosa was closed with a 4.0 chromic stitch. The exact same procedure was performed on the left whartons duct. Once complete the oral cavity was irrigated and cleaned. Ultrasound was then brought into the field. Under direct visual guidance 1mg/kg of botulinum toxin was injected into the parotid and submandibular glands using the hockey shaped ultrasound probe. Having tolerated the procedure well, the patient was turned back over to anesthesia, awakened and transferred to the recovery room in stable condition.
Results:
There were no complications encountered before, during, or after the procedure. The patient was followed in clinic for 1 year and the patient’s care giver reported satisfactory reduction in sialorrhea.
Discussion:
This video shows the steps of performing a 4-gland duct ligation with botulinum toxin injections. It is a commonly indicated procedure in children under 5 years of age for chronic sialorrhea refractory to other treatment options. While not first line therapy, this procedure should be heavily considered for due to post-operative success and care giver satisfaction.
References:
Jean-Paul Meningaud, Poramate Pitak-Arnnop, Luc Chikhani, Jacques-Charles Bertrand, Drooling of saliva: A review of the etiology and management options, Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontology, Volume 101, Issue 1,2006, Pages 48-57, ISSN 1079-2104
Little, S.A., Kubba, H. and Hussain, S.S.M. (2009), An evidence-based approach to the child who drools saliva. Clinical Otolaryngology, 34: 236-239. https://doi-org.libproxy.uams.edu/10.1111/j.1749-4486.2009.01917.x
Khan WU, Islam A, Fu A, et al. Four-Duct Ligation for the Treatment of Sialorrhea in Children. JAMA Otolaryngol Head Neck Surg. 2016;142(3):278–283. doi:10.1001/jamaoto.2015.3592
Excision of Facial Venous Malformation
Introduction:
Facial venous malformations are challenging vascular anomalies that can significantly impact a patient’s quality of life. These malformations, characterized by abnormal clusters of dilated veins in the facial region, can cause significant cosmetic deformities, bleeding, and functional impairments. Surgical excision of facial venous malformations is a treatment option, aiming to address both the concerns and functional limitations associated with these vascular anomalies.
Case presentation:
The affected area on the lateral aspect of the upper eyelid margin was treated with a YAG laser set at 20 watts and one-second exposure time. This was followed by excision of a 1 x 2 cm segment of the affected skin above the eyelid margin. Using electrocautery, the skin, subcutaneous tissue, and venous malformation were dissected, avoiding branches of the facial nerve to the orbicularis oculi muscle. The incision was carried around the obvious margins of the malformation down to the temporalis muscle fascia. The dissection was performed underneath the lesion until it was completely resected. After excision of a portion of the eyebrow involved in the malformation, the deeper parts of the upper eyelid and orbicularis muscle affected by the venous malformation were removed. The deep portion of the dissection was not very vascular and was controlled with the bipolar and monopolar cautery. To achieve primary closure, we carefully undermined the forehead and facial skin. The lower facial skin flap was elevated and advanced, and primary closure was achieved with Vicryl sutures. Closure of the eyelid skin to the lateral forehead skin followed with chromic and Vicryl sutures to alleviate tension. Although the larger vascular lesion was excised from the skin and subcutaneous tissue, residual malformation remained around the upper eyelid and lateral orbital rim. This was dissected under the skin to remove the vessels and preserve the eyelid skin. Post-procedure, Mastisol and Steri-Strips were applied to the suture line to relieve tension and help wound healing. The estimated blood loss was less than 30 mL. The patient had no complications and did well.
Conclusion:
In this case, the surgical intervention effectively removed most of the facial venous malformation. Despite some residual malformation, the procedure yielded satisfactory outcomes with no postoperative complications. The residual malformation in the upper eyelid can be controlled with a YAG laser and/or sclerotherapy.
Endoscopic removal of TM cholestestoms
A 3 yo girl was referred to the ENT clinic after her PCP noticed an abnormal TM on the left.
She has a history of a 2 ear infections prior to presentation. She is asymptomatic, with no pain and no drainage from her TM. Her audiogram was normal. Her physical eventually revealed the presence of a relatively large keratin pearl on her TM, without obvious middle ear effusions. After a short period of observation the family decided to have it removed.
The case was performed endoscopically in a trans-canal approach. The lesion was dissected mainly with a straight pick. The fibrous layer underneath was found to be intact and no myringoplasty was necessary.
The patient was was seen again 2 months post-op and her TM was found to be normal with a normal audiogram.
Myringoplasty Using a Human Birth Tissue Allograft
This video demonstrates a myringoplasty procedure using Neox RT – a human birth tissue allograft – to repair a tympanic membrane perforation in a pediatric patient. We employ a “sandwich” technique, in which pieces of the allograft are placed both medial and lateral to the perforation. After partially filling the middle ear with dry, absorbable gelatin sponge, trimmed pieces of allograft are inserted sequentially in underlay and overlay fashion to remain medial and lateral to the perforation. Both the underlay and overlay pieces cover the perforation and overlap the native tympanic membrane around the perforation. More absorbable sponge is then inserted lateral to the graft to hold it in place against the tympanic membrane. Finally, antibiotic drops and bacitracin ointment are placed in the canal.