The video shows a new, minimally invasive technique for endoscopic repair of LC1 in children using cold steel instruments.
Specialty: Pediatric Otolaryngology
Gingival Vestibuloplasty in a Patient With Cleft Lip and Palate Using Birth Tissue
After informed consent was obtained the patient was brought to the operating room and placed in the supine position. The correct patient and procedure were identified and a Time Out was performed. After induction of general anesthesia, patient was intubated transnasally from right nostril. The table was turned to 90 degree and head was extended. 2% xylocaine with 1:100,00 epinephrine was injected over the left side of the maxillary gingivolabial sulcus.
Patient was prepped and draped in usual fashion.
Approximately 3 cm long incision was made along the mucogingival junction on the left side preserving the gingiva at the dental margin. This went from just to the right of the central incisor and over to the left molar. Supraperiosteal dissection was performed till the desired vestibular depth using predominantly a 15 blade. The periosteum was intentionally incised towards the height of the sulcus to promote attachment of the mucosa and maintain a deep sulcus with healing.
In the process of obtaining adequate release towards the intended sulcus depth, a connection to the nasal cavity was noted where the fistula was previously repaired. Tissue manipulation was done around the left nasal fistulous tract to allow for closure and it was then sutured with 5-0 vicryl in intermittent fashion.
Leak test performed showed no leak. Another suture in figure 8 fashion was then also applied over the closure to ensure no leak.
The free cut mucosal edge of the lip tissue was then sutured to the depth of the vestibular sulcus using interrupted 4-0 monocryl sutures. The remaining raw periosteal surface was covered with a 2×2 cm piece of Neox 1K membrane and was secured with intermittent sutures with 4-0 monocryl. Hemostasis was great throughout requiring very little cautery..
A periopak was created that was also mixed with doxycycline powder and applied over the surgical site. Mouth was closed to reshape the Coepack dressing to remove excess material and to prevent chipping off while eating.
Having tolerated the procedure well the patient was turned back over to anesthesia, awakened and transferred to the recovery room in stable condition.
Cartilage push through myringoplasty with T-tube
We present in this video our innovative approach to mild to moderately sized perforations in the setting of chronic eustachian tube dysfunction with push through myringoplasty using tragal cartilage graft with primary T-tube. There was improvement in conductive hearing loss while allowing for stable middle ear ventilation with this technique.
Endoscopic Excision of Juvenile Nasopharyngeal Angiofibroma (JNA)
Abstract
Introduction :Juvenile Nasopharyngeal Angiofibroma (JNA) is a benign but a locally aggressive vascular tumor. This usually affects the prepubertal or adolescent males. This video highlights a safe and affective endoscopic technique for JNA resection with minimal intraoperative bleeding and morbidity .
Case presentation : A 17-year-old male presented with recurrent right sided epistaxis and constant nasal obstruction. Imaging revealed a hypervascular mass in the right nasopharynx extending into right nasal cavity and pushing the septum towards left side.
Method: 6 vessel cerebral angiogram was performed and the feeding vessels were embolized with cyanoacrylate glue. The patient underwent endoscopic endonasal resection using a bi-nostril, four-handed technique with image guidance.
Conclusion: Endoscopic resection of JNA offers excellent visualization and reduce morbidity. Proper preoperative planning, embolization, and anatomical knowledge are key to successful outcomes.
Surgeons:
Deepa Shivnani, MD
Speed Olivia, MD
Sidarth Patel, MD
Gresham Richter, MD, FACS
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
Video description –
This video demonstrates the endoscopic surgical excision of a Juvenile Nasopharyngeal Angiofibroma
Juvenile Nasopharyngeal Angiofibroma or JNA is a relatively rare benign neoplasm generally seen in prepubertal and adolescent males, usually present with nasal airway obstruction, recurrent unilateral epistaxis, headache and facial swelling. JNA grows in close proximity to the posterior attachment of the middle turbinate near the superior border of the sphenopalatine foramen and can extend anteriorly into the nasal cavity and septum superiorly into the sphenoid sinus and laterally toward the pterego-palatine fossa.
“This video demonstrates the endoscopic surgical excision of a Juvenile Nasopharyngeal Angiofibroma in a 17-year-old male presenting with recurrent epistaxis and nasal obstruction. Preoperative imaging revealed- A well-defined enhancing vascular lesion epicentered in right pterygomaxillary fissure and sphenopalatine foramen. The lesion measures approximately 4 x 3 x 3 cm in greatest dimensions. Superiorly there is erosion of floor of right sphenoid sinus with focal extension Inferiorly it extends in nasopharynx and right nasal cavity and abuts right middle and inferior turbinates. No intra-orbital or intracranial extension noticed.
Patient underwent preoperative embolization of the right common carotid artery. 6 vessel cerebral angiogram was performed. The hyper vascular blush seen in the nasopharynx consistent with the diagnosis of JNA. It was primarily supplied by bilateral internal maxillary artery branches. Supplying arteries were embolized with cyanoacrylate glue.
Patient was placed under general anesthesia with hypotensive technique. Nasal cavity was decongested with adrenaline-soaked patties. 0-degree and 30-degree rigid endoscopes were used throughout the procedure.”
Under the stereotactic guidance- Anterior and post ethmoidectomy & maxillary antrostomy was performed.
The antrostomy was then widened circumferentially using the microdebrider until the maxillary sinus mucosa could be easily visualized.
The middle turbinate was resected above the tumor and superior gently off of the tumor.
Tumor was bluntly distracted slowly releasing areas of adhesions using a mixture of bipolar cautery and microdebrider from the left lateral and posterior wall from the face of the sphenoid sinus.
The SPA was ligated with a hemoclip. Bipolar cautery was used to remove the final attachment and the tumor was freed. Once tumor was freed from all attachments except for the origin it was placed into the oropharynx. Careful blunt dissection was used to locate the neurovascular structures to check for any more tumor.
The tumor was removed through the oral cavity. The nasal cavity was packed with thrombin soaked gelfoam followed by surgiflo. Merocel was placed in right nares.
The tumor specimen itself measures approximately 3x 4 cm in diameter as seen here there were no complications during the procedure and the estimated blood loss was about 15 CC’s the patient is admitted overnight for post-operative monitoring and deemed stable for discharge on postoperative day one. Histopathology confirmed JNA,
To date the patient has no evidence of recurrence
Tips and tricks
Always evaluate the extent of the tumor on both CT and MRI. Identify feeding vessels and consider preoperative embolization if feasible.
Perform posterior septectomy and extended medial maxillectomy when needed for optimal exposure. Don’t hesitate to switch to a 30- or 45-degree scope for better visualization of lateral extensions.
Devitalize the tumor early by cauterizing or clipping the feeding branches from the internal maxillary artery. LigaSure or Bipolar cautery can significantly reduce intraoperative bleeding.
Lastly, Maintain hypotensive anesthesia and use local vasoconstrictors. Have adequate suction ready and use hemostatic agents like Surgicel or Floseal as needed.
Thank you
‘Coffee Bean’ Tonsillotomy
Intracapsular tonsillectomy (tonsillotomy) offers significant advantages over the extracapsular approach. By preserving residual tonsillar tissue and the capsule as a biological dressing, it protects the underlying musculature with its vessels and nerves, while delivering equivalent clinical outcomes with reduced complications of postoperative pain, dehydration, and bleeding. There is no standardized approach in performance of a tonsillotomy , unlike the extracapsular approach. Additionally, when performing a tonsillotomy on large hypertrophied tonsils, visualizing the posterior pillar—often hidden behind tonsillar tissue—can be challenging, potentially putting this muscular structure at risk for damage and negating the advantages of a tonsillotomy. We describe a standardized technique for tonsillotomy using a midline split within the tonsillar tissue, creating a “coffee bean” appearance that serves as a pivot point for retraction. This approach allows for more accurate distinction between the posterior tonsil and the pillar, resulting in more precise ablation.
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. Neox RT is indicated as a wound covering for dermal ulcers or defects, but it holds further utility for myringoplasty. Birth tissue contains growth factors that stimulate epithelialization, as well as extracellular proteins that furnish scaffolding material for wound repair. These properties make it a natural and appealing option to induce tympanic membrane regeneration and healing.
We employ a “sandwich” technique, in which pieces of the allograft are placed both medial and lateral to the perforation. Simple overlay and underlay techniques have been tried with success, but the allograft is packaged as a single piece that affords enough material to craft two smaller pieces. The simultaneous placement of medial and lateral grafts not only avoids waste but may increase success.
Both pieces are trimmed to be slightly larger than the perforation. After freshening the edges of the perforation with a Rosen pick and 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.
Single- Stage Endoscopic Posterior Cricoid Split & Rib Graft Placement in Infant
This video provides an elucidation of the surgical steps involved in performing a single-stage endoscopic posterior cricoid split & rib graft placement in infant with congenital subglottic stenosis.
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.
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