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

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.

Your 30-second teaser has ended. Log in or sign up to watch the full video.

Newsletter Signup

"*" indicates required fields