Per Oral Endoscopic Myotomy (POEM) for Zenker’s Diverticulum

CAC (Coblation Assisted Cordectomy) in Bilateral Vocal Cord Palsy –tips & tricks

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 !

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Temporal Artery Biopsy – gold standard for the diagnosis of temporal (giant cell) arteritis

A 49-year-old female presented with a one-year history of right frontal headaches, not controlled despite OTC medication. Work up with head CT revealed an osteoma of the right frontal sinus. The patient experienced no improvement in headache severity and elected to have surgical intervention.

Methods: ENT Fusion Navigation system was used during the entire case.  A ball-tip probe was used to fracture out the uncinate bone and a backbiter was used to remove the uncinate in its entirety.  The natural ostium of the right maxillary sinus was then visualized.  Again, the backbiter was used to remove tissue anterior to the natural ostium. A straight Tru-Cut was used to remove the ostium towards the posterior fontanelle. The right middle turbinate was resected in order to gain sufficient access for the resection of the osteoma.  In order to remove the right middle turbinate, a turbinate scissors were used to make 3 cuts along the attachment of the middle turbinate and this was pulled down.  A down biter was used to open up the maxillary sinus inferiorly. There was no tissue seen in the maxillary sinus. After this was done, an ethmoidectomy was performed by placing a J-curette behind the ethmoid bulla point anteriorly.  This ethmoid bulla was removed along with several other anterior ethmoid cells.  After this was done, a frontal sinus seeker was used to identify the right frontal osteoma.  The patient did not have a right frontal sinus. Instead, an osteoma was in the area of what would have been the right frontal sinus or nasal frontal outflow tract.  Image guidance was meticulously used to identify the osteoma.  A 70-degree frontal drill was used and this osteoma was slowly drilled to remove as much as possible.   Drilling was done from the posterior edge of the osteoma up to the skull base superiorly, to the lamina papyracea laterally and all bone that could be safely removed was removed. A right frontal propel stent was placed in the bony cavity created by the drill out and after this, the sinus was irrigated and suctioned.

Results: The patient was sent to recovery in good condition and no adverse reactions were reported by the surgeon or patient.

Surgeons: Alissa Kanaan, MD. Zachary V. Anderson, MD.

Institution: Department of Otolaryngology – Head and Neck Surgery at the University of Arkansas for Medical Sciences.