The video demonstrates tonsillectomy surgery with monopolar diathermy technique.
Specialty: Sleep Apnea
Barbed Reposition Pharyngoplasty as Surgical Management of Obstructive Sleep Apnea
Background:
While continuous positive airway pressure (CPAP) remains the gold standard for management of obstructive sleep apnea (OSA), surgical management is nonetheless a good alternative for patients that are unable to tolerate CPAP therapy. Pharyngoplasty is one such option. First described in 1976 by Dr. Ikematsu and popularized in the US by Dr. Fujita in 1981, the goal of the surgery is to suspend the velopharynx anterolaterally to improve patency of the airway for patients with collapse at the level of the velopharynx. Since its inception, it has undergone many iterations. This video demonstrates the steps to performing barbed reposition pharyngoplasty, a technique that has gained in popularity due to its short operative time and decreased post-operative morbidities. It utilizes the unique properties of V-loc sutures to evenly distribute tension when suspending the soft palate. Pharyngoplasty are best suited for patients with collapse at the level of the velopharynx and are not recommended for patients with significant posterior collapse at the level of the base of tongue.
Case Overview:
45-year-old male with BMI of 33.1 and past medical history of OSA with poor sleep quality secondary to CPAP intolerance. Updated polysomnogram demonstrated moderate OSA with AHI of 15.7 with 1 central apnea. Physical examination demonstrated 1+ bilateral tonsil size and Friedman 3 palate position.
Pre-operative drug induced sleep endoscopy demonstrated mixed anteroposterior collapse of the velopharynx, partial lateral wall oropharyngeal collapse, with no significant collapse at the level of the base of tongue, hypopharynx, and epiglottis.
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.
Hypoglossal Nerve Stimulator Implantation: 2-Incision Technique
Hypoglossal Nerve Stimulator Implantation: 2-Incision Technique Authors: Cheryl Yu, MD1; Nilan Vaghjiani, BS1; Ryan Nord, MD1 1Virginia Commonwealth University School of Medicine, Department of Otolaryngology/ Head and Neck Surgery, Richmond, VA
Background:
Obstructive sleep apnea is a worldwide health problem that affects all groups. Given its systemic associations with comorbid diseases, it ultimately increases lifetime risk of mortality and thus, should not be a disorder taken lightly. Although continuous positive airway pressure is thoroughly acknowledged as the gold standard for treating OSA with studied efficacy, adherence remains challenge. Given such, hypoglossal nerve stimulation therapy presents a revolutionary alternative for those with moderate to severe degrees of OSA who are unable to tolerate standard CPAP therapy. It has been studied to be very efficacious in treating the disorder, with reductions in apneas up to 70-80%. The surgery itself is less invasive, now even more so with the 2-incision technique, when compared to other surgical options such as mandibular advancement or other upper airway surgery, with decreased post-operative pain and healing times. Adherence to therapy is generally superior as the majority prefer it over traditional positive airway pressure therapy. Overall, hypoglossal nerve stimulator implantation is an effective, tolerable long-term alternative treatment option for those with OSA.
Case Overview: 84-year-old female with BMI of 31 with past medical history significant for hypertension, atrial fibrillation, and obstructive sleep apnea and inability to tolerate CPAP. Polysomnography revealed severe OSA with an AHI of 33 and minimal central or mixed apneas. Preoperative drug induced sleep endoscopy was performed noting complete anterior-posterior collapse of the velum, no collapse at the oropharynx, complete anterior-posterior collapse of the tongue base, and no collapse at the epiglottis. Patient was subsequently deemed an appropriate candidate for hypoglossal nerve stimulator implantation and elected to proceed with the procedure. The following video demonstrates her hypoglossal nerve stimulator implantation via the 2-incision technique detailing the procedure’s anatomic landmarks and corresponding steps.
Microdebrider Assisted Lingual Tonsillectomy
Microdebrider Assisted Lingual Tonsillectomy
Adrian Williamson, Michael Kubala MD, Adam Johnson MD PhD, Megan Gaffey MD, and Gresham Richter MD
The lingual tonsils are a collection of lymphoid tissue found on the base of the tongue. The lingual tonsils along with the adenoid, tubal tonsils, palatine tonsils make up Waldeyer’s tonsillar ring. Hypertrophy of the lingual tonsils contributes to obstructive sleep apnea and lingual tonsillectomy can alleviate this intermittent airway obstruction.1,2 Lingual tonsil hypertrophy can manifest more rarely with chronic infection or dysphagia. A lingual tonsil grading system has been purposed by Friedman et al 2015, which rates lingual tonsils between grade 0 and grade 4. Friedman et al define grade 0 as absent lingual tonsils and grade 4 lingual tonsils as lymphoid tissue covering the entire base of tongue and rising above the tip of the epiglottis in thickness.3
Lingual tonsillectomy has been approached by a variety of different surgical techniques including electrocautery, CO2 laser, cold ablation (coblation) and microdebridement.4-9 Transoral robotic surgery (TORS) has also been used to improve exposure of the tongue base to perform lingual tonsillectomy.10-13 At this time, there is not enough evidence to support that one of these techniques is superior.
Here, we describe the microdebrider assisted lingual tonsillectomy in an 8 year-old female with Down Syndrome. This patient was following in Arkansas Children’s Sleep Disorders Center and found to have persistent moderate obstructive sleep apnea despite previous adenoidectomy and palatine tonsillectomy. Unfortunately, she did not tolerate her continuous positive airway pressure (CPAP) device. The patient underwent polysomnography 2 months preoperatively which revealed an oxygen saturation nadir of 90%, an apnea-hypopnea index of 7.7, and an arousal index of 16.9. There was no evidence of central sleep apnea. The patient was referred to otolaryngology to evaluate for possible surgical management.
Given the severity of the patient’s symptoms and clinical appearance, a drug induced sleep state endoscopy with possible surgical intervention was planned. The drug induced sleep state endoscopy revealed grade IV lingual tonsil hypertrophy causing obstruction of the airway with collapse of the epiglottis to the posterior pharyngeal wall. A jaw thrust was found to relieve this displacement and airway obstruction. The turbinates and pharyngeal tonsils were not causing significant obstruction of the airway. At this time the decision was made to proceed with microdebrider assisted lingual tonsillectomy.
First, microlaryngoscopy and bronchoscopy were performed followed by orotracheal intubation using a Phillips 1 blade and a 0 degree Hopkins rod. Surgical exposure was achieved using suspension laryngoscopy with the Lindholm laryngoscope and the 0 degree Hopkins rod. 1% lidocaine with epinephrine is injected into the base of tongue for hemostatic control using a laryngeal needle under the guidance of the 0 degree Hopkins rod. 1. The 4 mm Tricut Sinus Microdebrider blade was set to 5000 RPM and inserted between the laryngoscope and the lips to resect the lingual tonsils. Oxymetazoline-soaked pledgets were used periodically during resection to maintain hemostasis and proper visualization. A subtotal lingual tonsillectomy was completed with preservation of the fascia overlying the musculature at the base of tongue.
She was extubated following surgery and there were no postoperative complications. Four months after postoperatively the patient followed up at Arkansas Children’s Sleep Disorders Center and was found to have notable clinical improvement especially with her daytime symptoms. A postoperative polysomnography was not performed given the patient’s clinical improvement.
Total Tonsillectomy
Total Tonsillectomy
Sarah Maurrasse MD, Vikash Modi MD
Weill Cornell Medicine, Department of Otolaryngology
Tonsillectomy is one of the most common surgical procedures performed in children. The two main indications for tonsillectomy are sleep disordered breathing and recurrent infections, both of which are common in the pediatric population. This video includes 1) a detailed introduction including relevant anatomy 2) a discussion of the indications for total tonsillectomy 3) surgical videos and diagrams to explain the steps of the surgical procedure and 4) an explanation of possible post-operative complications.
Partial Tonsillectomy
Partial Tonsillectomy
Sarah Maurrasse MD, Vikash Modi MD
Weill Cornell Medicine, Department of Otolaryngology
Tonsillectomy is one of the most common surgical procedures performed in children. The main indication for partial tonsillectomy is sleep disordered breathing, which includes a spectrum of disorders from primary snoring to obstructive sleep apnea (OSA). This video includes 1) figures of the anatomy relevant to partial tonsillectomy 2) a discussion of the indications for partial tonsillectomy and 3) surgical videos and diagrams that explain the steps of the surgical procedure.
Snare Tonsillectomy
Tonsillectomy is one of the most common surgeries performed today, yet debate continues regarding the best technique to avoid complications. We’ll review one method in this video, snare tonsillectomy, which is a “cold” technique. We’ll discuss it’s advantages over other methods, and a step-by-step instructional video.
Submental Intubation
Presented is a case of submental intubation performed prior to maxillomandibular advancement for the treatment of obstructive sleep apnea. Submental intubation is a viable alternative to tracheostomy for cases in which nasal intubation is contraindicated (e.g. trauma), or uninterrupted access to the oral cavity is preferred. [1] Briefly, the technique consists of performing oral intubation, and then exteriorizing the endotracheal tube through a tract created from the floor of mouth to the submental triangle. At the end of the case, the tube can be passed into the oral cavity, returning to an oral intubation.
Surgeon: Raj C. Dedhia, MD, MSCR, Department of Otolaryngology, Emory University School of Medicine
Video Production: Clara Lee, MS4, Emory University School of Medicine
Internal Nasal Valve Stabilization
Dynamic internal nasal valve collapse is common form of nasal valve collapse that can be difficult to address surgically. There have been many surgical techniques described to stabilize and improve the function of the internal nasal valve. Our presented technique is a simple and reproducible surgical technique that has proved reliable in treatment of dynamic internal nasal valve collapse. This video clearly describes and demonstrates our internal nasal valve stabilization technique.