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.

Posterior Pharyngeal Flap for Large Gap Velopharyngeal Insufficiency

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.

Tracheostomy with Tracheocutaneous Adhesion and Cartilage Preservation Technique

The video describes a tracheostomy technique. The tracheostomy performed by  tracheocutaneous adhesion that is suturing stoma to skin directly without violating cartilage during the surgery. This result in stoma that opens directly in trachea without risk of false tract formation. This technique makes tube reinsertion easier in accidental decannulation and avoid consequences of false tract.

The Advantage of this technique is avoidance of tracheal cartilage violation and subsequent airway deformity. It allow faster maturation of tract. Lastly, prevent false tract formation and subsequent complications related to it.

This technique was described by Dr.Jaber Alshammeri, consultant pediatric otolaryngology and director of pediatric otolaryngology fellowship at King Abdullah Specialized Children Hospital, Ministry of National Guard Health Affairs, Riyadh, Kingdom of Saudi Arabia.

Endoscopic Anterior and Posterior Cricoid Split

This video provides an elucidation of the surgical steps involved in performing an endoscopic anterior and posterior cricoid split in a neonate with bilateral vocal fold paralysis.

Endoscopic laryngeal web repair

This video elucidates the procedural technique employed for endoscopic laryngeal web repair in pediatric patients, wherein a laryngeal anterior commissure stent (LACS) is inserted.

It delineates the steps of the surgical intervention, as well as the subsequent postoperative assessment by awake fiberoptic nasolaryngoscopy examination.

Excision of a Dermoid Cyst

This video demonstrates the excision of a supraorbital dermoid cyst in a pediatric patient. This lesion was located just superior to the right lateral orbit.

Endoscopic Resection of Forehead Arteriovenous Malformation

This video describes the novel approach to removing an arteriovenous malformation (AVM) of the forehead using an endoscopic technique in a trichial incision. A 17-year-old presented to the Otolaryngology clinic with facial pain and headaches, as well as a pulsatile mass on her forehead. Angiography was performed and proved the mass to be an AVM. Angiography also revealed that one of the feeders was coming directly off the ophthalmic artery. She had no other neurological or ophthalmological symptoms. However, because of the ophthalmic artery feeder, embolization could not be performed due to the risk of blindness.

We made an incision in the hairline, down to the subgaleal plane, and the entirety of the mass was revealed. Using endoscopy for visualization, the feeder vessels were carefully tied off using a knot pusher and ligated. The vessels were then cut and the mass removed. The skin was closed and a pressure dressing placed.

At her post-operative visits, the patient was very pleased with the cosmetic outcomes of the surgery. Of note, there was no facial numbness, facial nerve weakness, or vision changes. We will continue to monitor the child, but as of yet there has been no evidence of recurrence of her AVM.

Selective Stapedial tendon and Tensor Tympani tenotomy for the treatment of Middle Ear Myoclonus in a pediatric patient

Objective tinnitus is a rare phenomenon whereby a patient perceives sound in the absence of external auditory stimuli, that is also observed by the examiner. Unlike subjective tinnitus which is thought to be somatosensory and usually difficult to cure, objective tinnitus is more likely to have an identifiable cause amenable to treatment. The differential for objective tinnitus includes aberrant vascular anatomy affecting the temporal bone, patulous eustachian tube function, and abnormal myoclonic activity of the palatal or middle ear muscles.1  

We present a 16-year-old female who presented for evaluation of objective tinnitus. On physical examination, an intermittent rhythmic clicking was identified. Visualization of both the tympanic membrane and palate during active audible tinnitus was observed and found to be normal. A hearing test was performed demonstrating normal hearing and speech thresholds as well as normal tympanogram. Acoustic reflex testing demonstrated absent decay in both ears and  spontaneous discharge for the right ear in response to both high and very low stimulus indicating abnormal stapedial and tensor tympani function. MRA demonstrated normal vascular anatomy and MRI was obtained demonstrating normal anatomy without lesions of the brainstem, cochleovestibular nerves, or ear or mastoid pathology. The patients was subsequently diagnosed with isolated middle ear myocolonus (MEM). Treatment options including medical versus surgical therapy were discussed as has previously been described. The patient ultimately elected for surgical tenotomy of the stapedial and tensor tympani tendons. Using endoscopic technique, a middle ear exploration was performed. Canal injection was performed with standard tympanomeatal flap elevation was assisted with epinephrine pledgets. The Annular ligament was identified and the middle ear was entered. Additional dissections was performed superiorly, and the chorda tympani nerve was identified and preserved. The stapedial tendon was visualized emanating from the pyramidal eminence to the posterior crus of the stapes. Balluci scissors were used to sharply incise the tendon and the remaining ends were reflected using a Rosen needle to prevent re-anastamosis. Additional dissection along the malleus was performed to gain access to the tensor tympani tendon. A 30 degree angled endoscope was utilized to visualize the tensor tympani tendon extending forward from the cochleariform process to the neck of the malleus. The angled 6400 Beaver blade was used to sharply incise the tendon, requiring multiple passess due to the thickness of the tendon. The sharply incised ends of both tendons were clearly visualized. The tympanomeatal flap was re draped and secured with gel foam packing. The patient was seen in follow up three weeks post operatively with a well healed ear drum, resolution of her objective tinnitus, normal hearing, and absent stapedial reflexes. The patient and mother were happy. Endoscopic stapedial and tensor tympani tenotomy is a feasible technique for isolated MEM in the pediatric population.

Endoscopic Nd:Yag and Bleomycin Injection for the management of a Hypopharyngeal Venous Malformation

Venous malformations (VM) are congenital lesions, frequently affecting the head and neck, with poor respect for tissue planes. Established treatments include observation, sclerotherapy, laser, and surgical resection.1  

Lesions affecting the upper airways present unique challenge due to frequent unresectability and difficult access/exposure for alternative standard treatments. We describe our approach of standard endoscopic airway techniques for the administration of advanced treatment modalities including simultaneous laser and sclerotherapy for an extensive airway VM.

Our patient is a 16-year-old female with an extensive multi-spatial VM with associated airway obstruction.  The patient suffered from severe obstructive sleep apnea (OSA) and continuous positive airway pressure (CPAP) dependence as a result of airway compression. Direct laryngoscopy and bronchoscopy demonstrated extensive venous staining and large vascular channels of the hypopharynx. Lumenis Nd:Yag laser (Yokneam, Israel) via 550 micron fiber was passed under telescopic visualization. Treatment via previously described “polka dot” technique was performed (15W, 0.5 pulse duration) with immediate tissue response. The largest vascular channel was accessed via 25-gauge butterfly needle. Immediate return of blood following lesion puncture confirmed intralesional placement. Reconstituted bleomycin (1 U/kg; max dose = 15 U per treatment) was injected and hemostasis achieved with afrin pledgets. The patient was intubated overnight. She was extubated the next morning and advanced to a regular diet, discharging post-operative day two. Post-operative flexible laryngoscopy demonstrated significant improvement in the treatment areas, and follow up sleep study demonstrated sleep apnea resolution with liberation of her CPAP therapy.

Branchial Cleft Cyst Excision

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. 

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