The following video demonstrates the authors’ method for performing a tracheostomy in a pediatric patient. Details of important anatomical landmarks and surgical technique are demonstrated in the video.
Authors:
Chrystal Lau, BA. University of Arkansas for Medical Sciences.
Brad Stone, BA. University of Arkansas for Medical Sciences.
Austin DeHart, MD. Arkansas Children’s Hospital.
Michael Kubala, MD. University of Arkansas for Medical Sciences.
Gresham Richter, MD. Arkansas Children’s Hospital.
Tracheostomy performed in a 4-month-old infant with severe obstructive sleep apnea requiring chronic oxygen supplementation.
Tracheostomy is becoming an increasingly performed surgical procedure in pediatric populations. Once an emergency procedure primarily indicated for acute airway obstruction secondary to infectious etiologies, tracheostomy is now more commonly seen in children requiring prolonged ventilator support due to cardiopulmonary or neurological impairment. Other indications for tracheostomy include congenital upper airway obstruction, failure to wean from conventional ventilation, and pulmonary toilet. These patients are most often very premature patients less than one year of age, with this demographic likely reflecting today’s increasing survival rates of preterm infants and those undergoing cardiac repair.
Relative contraindications to elective tracheostomy include: uncorrectable coagulopathy, anatomic distortions (aberrant vasculature, scarring from previous neck surgery, tumor, etc), the inability to extend the cervical neck, and active local inflammation or infection.
An appropriately sized tracheostomy tube should be selected and checked prior to the procedure. If a cuffless tube is being utilized, the cuff should be evaluated for leaks.
Shoulder roll and head ring will be used to extend the patient's neck and stabilize the head. Standard prep and sterile drape should be used.
Careful preoperative evaluation of the patient is necessary to assure that no other intervention can be undertaken that may avoid a tracheostomy procedure: microlaryngoscopy and bronchoscopy, chest x-ray, blood tests, cardiology review if suspicious for cardiac pathology.
Although the basic tracheostomy technique is similar between adult and pediatric patients, infants have shorter necks with more fatty tissue. This can make the cricoid and thyroid cartilages more difficult to palpate. The infant larynx is approximately 1/3 the adult size, is more pliable, and is situated more superiorly and anteriorly in the neck.
In pediatric patients, tracheostomy tubes are secured to the neck with cotton twill ties instead of being sutured to skin. This is because skin in pediatric patients is very lax and can result in accidental decannulation going unnoticed.
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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 Pediatric Tracheostomy.