Video Library

Educational/Technical Point(s): Endoscopic marsupialization of vallecular cysts is a safe and effective treatment method with improved visibility, minimal recovery and acceptably low recurrence rate.1

Introduction:

Vallecular cysts are rare but important causes of neonatal stridor and dysphagia. When present, they can cause aspiration and dyspnea or apnea. They are readily identified on flexible fiberoptic laryngoscopy, and treatment is solely surgical though multiple techniques exist.

Case Presentation:

We present a 6-week old infant with coughing, choking, and gasping spells with feeds admitted for further workup. Flexible laryngoscopy demonstrated a large, well circumscribed vallecular cyst. Endoscopic marsupialization was recommended.

The decision to excise versus marsupialize is based on surgeon preference, however, we propose that cold steel marsupialization results in less tongue base dissection and lower opportunity for inadvertent iatrogenic injury.2,3

Technique:

Following intubation, the cyst was needle decompressed using an 18-gauge needle. It is our institutional preference to have on hand for every vallecular cyst induction in the event of inability to ventilate and the need to immediately decompress the cyst to secure the airway.

Following decompression, a three handed endoscopic technique was used to allow improved visualization and for educational purposes. Using a microlayngeal grasper to apply tension, the microlaryngeal scissors were used to sharply excise the redundant cyst lining.

Dissection was continued across the lingual surface of the epiglottis. This was continued circumferentially until the entirety of the cyst was excised. Hemostasis was achieved using Afrin soaked pledgets.

After ensuring adequate excision, silver nitrate was then used on the exposed mucosal surfaces for hemostasis. At the conclusion of the procedure, the patient’s prior grade 4 view was improved to grade 1.

Post operatively, the patient was admitted to the floor for observation overnight and given two doses of Decadron for post operative pain control. She was allowed to nurse with immediate improvement in symptoms and was discharged home post operative day 1. Flexible in-office laryngoscopy 3 weeks later demonstrated re-mucosalization of the tongue base, no evidence of recurrence, and resolution of symptoms.

Conclusion:

Endoscopic cold steel marsupialization of vallecular cysts is a safe and effective treatment method with improved visibility, minimal recovery and acceptably low recurrence rate.

The video shows a new, minimally invasive technique for endoscopic repair of LC1 in children using cold steel instruments.

This video demonstrates a transventricular subtotal excision of a recurrent laryngeal saccular cyst, including partial excision of the false vocal cord, performed using the COMET approach (Combined Microscopic and Endoscopic Technique). The cyst had initially been managed with supraglottic decompression on the 5th day of life, which failed, leading to recurrence with progressive respiratory distress over the following days and necessitating re-intubation.

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.

This video demonstrates the bilateral suprazygomatic maxillary nerve (SZMN) block performed using both landmark-based and ultrasound-guided techniques for intraoperative and postoperative analgesia in a 12-month-old child undergoing cleft palate repair. The maxillary nerve, located within the pterygopalatine fossa, is the second division of the trigeminal nerve (V2) and is a purely sensory nerve that supplies sensation to the midface, including the palate.

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.