This video teaches its viewers about facial capillary malformations, possible sequelae, as well as a treatment option, flash pulse dye laser.
Authors: Maya Merriweather, BS and Richter T. Gresham, MD FACS
Email: mmerriweather@uams.edu and GTRichter@uams.edu
Institutions: University of Arkansas for Medical Sciences and Arkansas Children’s Hospital
Laser eye protection was secured on the patient, surgeon and observers. A cheek, chin and lower lip capillary malformation was treated with 595-nm flash pulsed dye laser (PDL) on a pediatric patient for their yearly maintenance. The targeted area measured 25cm2. During the first pass the fluence was set at 9J/cm squared for a pulse duration of 1.5ms. The spray/delay cool setting was set to 40/20. The setting of the fluence and pulse duration were changed to 8.J/cm2 and 0.45ms respectively for a second pass allowing for complete coverage of the lesion. Assessment of the capillary malformation was assessed with digital photographs.
Flash pulse dye (PDL) at 585-595nm can be used as primary therapy for capillary malformations to prevent discoloration, growth and deformity.
Infections or inflammatory conditions of the affected skin. Avoid use the laser on areas of acute infections. Caution in dark (Fitzpatrick scale IV – VI) skin individuals as could lead to hypopigmentation.
Patient was sedated with general anesthesia in a sterile environment. Eye protection was given to all observers, patient, and surgeon.
In children with V1 facial distribution of the capillary malformation they should be evaluated for conditions associated with Sturge Weber Syndrome including an MRI of the brain to rule out meningeal involvement and Ophthalmology consult to rule out glaucoma. Full dermal examination should be performed for any other vascular lesions. Examine for associated hypertrophic conditions.
Caution and lower laser settings should be performed along vermilion border.
Advantages: Primary benefit of using the PDL is to disrupt the abnormal capillary beds and lighten the discolored skin. A second pass with variation in pulse duration will target different depths of the lesion.
Disadvantage: PDL treatment is unlikely to result in complete resolution.
Blistering, hypopigemntation, and hyperpigementation. Midline facial capillary malformations can be resistant to laser therapy.
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Thank you Dr. Richter for giving me the opportunity to perform research under your guidance. I have learned a lot about my subject matter, and the field of Otolaryngology. It was a pleasure working with you!
“Capillary Malformation: Boston Children's Hospital.” Boston Childrens Hospital, www.childrenshospital.org/conditions-and-treatments/conditions/c/capillary-malformation.
“Capillary Malformations.” Edited by Kiersten Ricci, Cincinnati Childrens, Feb. 2020, www.cincinnatichildrens.org/health/c/capillary.
Cole, Patrick D, et al. “Laser Treatment of Pediatric Vascular Lesions.” Seminars in Plastic Surgery, Thieme Medical Publishers, 21 Aug. 2007, www.ncbi.nlm.nih.gov/pmc/articles/PMC2884839/.
Rosenberg, Tara L., and Gresham T. Richter. “Lasers in the Treatment of Vascular Anomalies.” Current Otorhinolaryngology Reports, vol. 2, no. 4, 21 Sept. 2014, pp. 265–272., doi:10.1007/s40136-014-0065-6.
This video shows a transotic approach for a cochlear schwannoma in a 59-year-old female who presented with sudden sensorineural hearing loss in her left three years prior. She was found to have subsequent growth of her tumor on imaging and elected to undergo surgery. The transotic approach is a valuable approach within the armamentarium of a skull base team and differs from the transcochlear approach in the handling of the facial nerve. Techniques for ear canal overclosure, eustachian tube packing and mastoid obliteration are also highlighted.
Here, we have a 39 yrs old female with complaints of noisy breathing for last two years post thyroidectomy. Flexible laryngoscopy confirmed bilateral vocal cord paralysis. She was planned for coblation assisted cordectomy.
Patient was taken up for procedure under general anaesthesia. She also started having stridor after induction. Nasopharyngeal intubation with spontaneous breathing technique was used. Entropy leads were placed over forehead to monitor the depth of anaesthesia. Tube position was confirmed with endoscopic view and Benjamin lindohlm laryngoscope was suspended. As the patient was spontaneously breathing, the stridor became more prominent, with stable vitals and the procedure was continued. The vocal cord retractor was fixed and coblation wand was then used with 7:3 settings for ablation and coagulation respectively. The surgical limits were-anteriorly the junction between ant 2/3 and post 1/3 of the vocal cord, posteriorly just anterior to the vocal process of arytenoid to prevent cartilage exposure and post operative granulations. Superely till the ventricle and inferioly till the medial most surface of the subglottis. Laterally approx. 5 mm depth was defined to prevent injury to the superior laryngeal artery branch and further bleeding. Once the final airway was achieved , the topical lignocaine was used to prevent laryngeal spasm post extubation.
The patient was shifted to the ward without oxygen, the voice was assessed on post op day 2.
Patient was called for follow up on post op day 14th and good voice outcomes were achieved.
So lets have a look on some tips & tricks for the safe procedure—–
Nasopharyngeal insufflation technique with entropy monitor will give adequate and safe surgical field
2. Appropriate exposure will help you to delineate the surgical margins
3. Topical anaesthesia before and after the procedure will prevent sudden laryngeal spasm
4. Firm holding of coblation device will help to prevent injury to surrounding structures like anterior 2/3 vocal cord, opposite side vocal cord, medial surface of vocal cord or aryteroid posteriorly
5. Do not ablate more laterally to prevent bleeding, if at all it happens, use patties or coagulation switch for hemostasis.
6. And at the end of the procedure ,use catheter suction to suck out blood clots or saline from the airway if any….
To Conclude-Coblation Assisted Cordectomy( CAC) can be performed safely with good outcomes in case of bilateral vocal cord paralysis using tubeless anesthesia technique without tracheostomy !
We present the harvest of a osteocutaneous fibula free flap for head and neck reconstruction performed at the University of Cincinnati. This reconstructive technique has a wide variety of implications but has found greatest utility in the reconstruction of mandibular defects.
Review Flash Pulse Dye Laser (595nm) Therapy on Facial Capillary Malformation.