Management of subglottic stenosis with endoscopic stent placement

History of airway stenosis, s/p laryngotracheal reconstruction. Developed restenosis, and balloon dilated three times.

In this video we describe our technique for airway stent insertion and its securing to the neck skin.

Balloon dilation of the airway expanded the airway to its appropriate size. After sizing, an 8mm modified Mehta laryngeal stent with rings (Hood Laboratories, Pembroke, Mass., USA)is inserted in the airway with laryngeal forceps. The scope is inserted into the stent to verify its position. Then a 2.0 prolene stitch is taken through the neck, trachea, stent, and taken out through the contralateral skin. This is performed under visualization with a 2.3mm endoscope through the stent. The needle is then re-inserted through the exit puncture and again taken out next to the entry puncture after passing through a subcutaneous tunnel, without re-entering the stent. A small skin incision is performed between the two prolene threads. Multiple knots are taken over an angiocath, which is then buried under the skin.

The stent is taken out 2-6 weeks after the procedure. A neck incision is performed, the angiocath is identified, the knot is cut and the stent is removed under the vision of the endoscope.

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.

Pediatric Tracheostomy

The following video demonstrates the authors’ method for performing a tracheostomy in a pediatric patient. Details of important anatomical landmarks and surgical technique are demonstrated in the video.

Authors:
Chrystal Lau, BA. University of Arkansas for Medical Sciences.
Brad Stone, BA. University of Arkansas for Medical Sciences.
Austin DeHart, MD. Arkansas Children’s Hospital.
Michael Kubala, MD. University of Arkansas for Medical Sciences.
Gresham Richter, MD. Arkansas Children’s Hospital.

Closure of H-type tracheoesophageal fistula

We present the case of a 20 months old boy with developmental delay and chromosomal abnormality, who presented with a history of chronic aspiration. He was found to have a laryngeal cleft, which was injected with Prolaryn, then formally repaired, twice. Despite an initial a negative swallow study, the patient had persistent aspiration. A repeat direct laryngoscopy and bronchoscopy finally revealed the presence of an H-type tracheoesophageal fistula (TEF). We describe here the steps of the surgical repair of an H-type tracheoesophageal fistula.

Endoscopic resection of a vallecular cyst in a pediatric patient

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.

Pediatric Tracheostomy with Maturation Sutures

Procedure: This video demonstrates the operative method of pediatric tracheostomy with maturation sutures of the tracheocutaneous fistula tract. Introduction: Pediatric tracheostomy provides an alternate airway. Indications: This procedure is done to alleviate upper airway obstruction, facilitate prolonged mechanical ventilation, or pulmonary toilet. Contraindications: There are no absolute contraindications to this procedure, however, like any procedure, it has recognized possible risks. Conclusion: Pediatric tracheostomy with maturation sutures provides an alternate airway to bypass obstruction, facilitate long term ventilation, or pulmonary toilet.

Supraglottoplasty and Epiglottopexy for Sleep-Variant Laryngomalacia

Here we present a 6-year-old girl with sleep-variant laryngomalacia treated successfully with endoscopic epiglottopexy and supraglottoplasty.

Johanna L. Wickemeyer, MD1
Sarah E. Maurrasse, MD2,3
Douglas R. Johnston, MD, FACS2,3
Dana M. Thompson, MD, MS, FACS2,3

1Department of Otolaryngology—Head & Neck Surgery, University of Illinois—Chicago, 1855 West Taylor Street, Chicago, IL 60612
2Division of Pediatric Otolaryngology—Head and Neck Surgery, Ann and Robert H. Lurie Children’s Hospital of Chicago, 225 E. Chicago Ave, Chicago, IL 60611
3Department of Otolaryngology-Head and Neck Surgery, Northwestern University Feinberg School of Medicine, 420 E Superior St, Chicago, IL 60611

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