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.
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
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.
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.
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.
Endoscopic cold steel marsupialization of vallecular cysts is a safe and effective treatment method with improved visibility, minimal recovery and acceptably low recurrence rate
None
None
1 Li Y, Irace AL, Dombrowski ND, Perez-Atayde AR, Robson CD, Rahbar R. Vallecular cyst in the pediatric population: Evaluation and management. International Journal of Pediatric Otorhinolaryngology. 2018 Oct 1;113:198-203.
2 Chen EY, Lim J, Boss EF, Inglis Jr AF, Ou H, Sie KC, Manning SC, Perkins JA. Transoral approach for direct and complete excision of vallecular cysts in children. International journal of pediatric otorhinolaryngology. 2011 Sep 1;75(9):1147-51.
3 Leibowitz JM, Smith LP, Cohen MA, Dunham BP, Guttenberg M, Elden LM. Diagnosis and treatment of pediatric vallecular cysts and pseudocysts. International journal of pediatric otorhinolaryngology. 2011 Jul 1;75(7):899-904.
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 Neonatal Endoscopic Cold Steel Vallecular Cyst Marsupialization.