Posterior displacement of the epiglottis secondary to lingual tonsil hypertrophy is a common cause for persistent obstructive obstructive sleep apnea after adenotonsillectomy in the pediatric population. By use of an operating micorscope an endoscpoic technique for lingual tonsillectomy and a epiglottopexy is described.
1. Nasotracheal intubation with a laser safe tube
2. Tooth guard placement
3. Lindolm laryngoscope inserted and suspended to a Mayo stand
4. Operating microscope with 400mm lens is used
5. Laser safety precautions implemented
6. Coblation wand (Setting 8) is used to debulk the lingual tonsils. Special care is taken to not enter the tongue base musculature. Laryngoscope is repositioned to access the right, center, and left lingual tonsils.
7. 75% of the lingual surface of the epiglottis, the entire vallecula, and the corresponding surface on the base of tongue is demucosalized with a carbon dioxide laser on 3-5 watts in a pulsed mode. In order to prevent aspiration, special care is taken to not demucosalize the 2 mm perimeter of the lingual surface of the epiglottis (lateral edges and tip).
8. Charred tissue is cleaned with an oxymetazoline soaked pledgelet
9. The epiglottis is secured to the base of tongue with 3 to 5 absorbable interrupted sutures. A 45 centimeter 5.0 polysorb on a CVF-21 needle (tapered) is used. Stitch is placed using a curved(right) alligator forcep first through the base of tongue and then through the perichondrium of the lingual surface of the epiglottis. All sutures are placed near the center of the base of tongue as to not injure the lingual arteries.
10. Aryepiglottic folds are divided with a cold steel to decrease tension on sutures
11. After all sutures are placed they are then sequentially tied with the aid of a knot pusher. Center suture knot is tied first followed by lateral suture knots.
12. Patient is extubated and taken to the pediatric intensive care unit to spend one night
13. Clinical swallow evaluation
14. Soft diet for one week
15. Antibiotics for 5 days
16. Steroids (Decadron 0.5mg/kg) are given at the time of surgery and every 8 hours for 24 hours. - See more at: https://www.csurgeries.com/video/lingual-tonsillectomy-with-epiglottopexy/udyidw6jqh#sthash.LVJut8sj.dpuf
Lingual tonsil hypertrophy resulting in obstructive sleep apnea
Cervical spine clearance Poor endoscopic exposure
See steps 1-5 under "Procedure"
Polysomnogram Sleep endoscopy Cervical spine clearance - See more at: https://www.csurgeries.com/video/lingual-tonsillectomy-with-epiglottopexy/udyidw6jqh#sthash.LVJut8sj.dpuf
Lingual tonsils Epiglottis Aryepiglottic folds
Low morbdity Endoscopic approach
- Infection: post operative antibiotics for 5 days - Bleeding: During coblation tongue base musculature is not violated. Sutures in the base of tongue are kept very close to midline. - Aspiration: special care is taken to leave a rim of mucosa along the perimeter of the lingual surface of the epiglottis - Epiglottopexy stitch dehiscence: Aryepiglottic folds are divided to decrease tension on sutures.
1. Oomen K, Modi VK. Epiglottopexy with and without Lingual Tonsillectomy. Laryngoscope. 2014 Apr; 124(4):1019-22