Endoscopic Repair of Tracheal-bronchial Sinus Tract

Contributor: Deepak Mehta (Children’s Hospital of Pittsburgh)

Endoscopic Repair of Tracheal-bronchial Sinus Tract: Clinical History: 6 year-old female with a history of tracheal-esophageal fistula s/p repair at birth and a right sided aortic arch. She has a recent history of 6 episodes of pneumonia requiring hospitalization. She had a normal modified barium swallow exam. CT chest revealed a tract arising from the posterior carina. Operative Course: The patient was taken to the OR and using a 5.0 rigid ventilating bronchoscope we are able to easily visualize the tracheal bronchial sinus tract originating from the posterior carina. A flexible suction catheter was used to probe the tract. It extended approximately 1.5cm. Then using a Urologic Bugbee electrocautery, we de- epithelialized the tract. Next, Tisseel fibrin sealant was injected into the tract, closing it off. The bronchoscope was removed and the patient was admitted overnight for observation. She did well with no desaturations or complications and was discharged home on post op day #1.

DOI: http://dx.doi.org/10.17797/nqf3kv0qyp

Injection Laryngoplasty for Type 1 Laryngeal Cleft

Schools: Children’s Hospital of Pittsburgh

Injection Laryngoplasty for type 1 laryngeal cleft is done with first identifying the deep cleft by palpation of the interarytenoid notch. Once a confirmation is made the larynx is suspended with a laryngoscope. Radiesse voice gel is then primed in a laryngeal needle and the needle is placed at the apex of the cleft. The needle is then pushed to palpate the cricoid cartilage with the bevel of the needle pointing towards the esophageal surface. The needle is then slightly retracted and about 0.2 ml of voice gel is injected. Care is taken not to make multiple punctures and the subglottisis watched so that the injection does not inadvertently go into subglottis.

DOI: http://dx.doi.org/10.17797/g5r116zy3n

Robotic Assisted Type 1 Laryngeal Cleft Repair

Contributors: Umamaheshwar Duvvuri (University of Pittsburgh Medical Center)

A DaVinci Robot is used to dock in with a 30 degree up telescope.The oral cavity is exposed using a FK retractor or a modified McIvor mouth gag( one with a flat blade). Robotic 5 mm Maryland forceps and 5 mm monopolar diathermy forceps is used. After getting a good exposure of the laryngeal cleft the diathermy at a setting of 4-5 watts is used to make the incision.and using the maryland forceps the laryngeal and esophageal flaps are created.A 5.0 PDS suture with a P2 tapered needle is used.The apex of the esophageal flap is first closed with suturing it.After this the apex of the laryngeal surface is closed.For a laryngeal cleft repair 2-4 sutures are required to obtain a closure. The sutures on the laryngeal surface are buried.The patient is kept intubated for a day or two to avoid excess movement of larynx. Pre and post operative treatment of reflux is important for healing.

DOI: http://dx.doi.org/10.17797/z17zngnuwp

Pediatric Robotic Epiglottopexy

This is a patient with persistant laryngomalacia with stridor and Obstructive sleep apnea at 3 years of age. A flexible laryngoscopy showed prolapse of epiglottis into the airway. The patient had nasotracheal intubation and a suture was place through the anterior tongue to pull it forward while a modified McIvor mouth gag was placed with a short blade to expose the tongue base and epiglottis. The DaVinci robot is then docked with a 30 degree forward lens. A 5mm maryland forceps and a 5 mm bovie is used.The epithelium off the tongue base and the lingual surface of epiglottis is then denuded with a bovie at a setting of 10 after this is done the epiglottis is sutured to the tongue base with a 4.0 vicryl suture. A total of two or three sutures are placed with 3-4 knots on each suture. The patient is extubated and monitered overnight with 2-3 doses of Steroids.

DOI: http://dx.doi.org/10.17797/z6vqam37jc

Endoscopic Balloon Dilation of Tracheal Stenosis

A 16 year old presented with stridor three after being intubated for a week following a head injury. Endoscopy revealed a long segment tracheal stenosis in a subacute phase. The airway was sized with a uncuffed 3.5 endotracheal tube with a leak at 20cm of water.This stenosis was Grade 3 Cotton-Myer classification. A 12 mm Vascular balloon (Boston Scientific-Blue Max) was placed in the in the airway with direct visualization and was dilated at 20 atmospheres for about a minute. The patient was under general anaesthesia but spontaneously breathing throughout the procedure. The patient was sized to a 6.5 endotracheal tube with a free leak after the dilation.

DOI: http://dx.doi.org/10.17797/n35d0ug41t

Epiglottopexy for Severe Laryngomalacia with Epiglottic Prolapse

Contributors: Deepak Mehta (Children’s Hospital of Pittsburgh of UPMC)

Laryngomalacia is the most common cause of stridor in newborn infants. The majority of cases resolve spontaneously. Common surgical therapy consists of division of the aryepiglottic folds combined with trimming of the arytenoid mucosa and/or cuneiform cartilages. Less frequently, epiglottopexy is required. Initially, flexible laryngoscopy illustrated prolapse of the epiglottis into the laryngeal lumen causing severe obstruction. Microlaryngoscopy, bronchoscopy, and supraglottoplasty (division of the aryepiglottic folds only) were performed, however improvement did not occur due to persistent epiglottic prolapse. Transoral epiglottopexy was performed. A Lindholm laryngoscope was used for exposure. A needle point cautery was used to remove the mucosa of the lingual surface of the epiglottis and the base of tongue. Alternatively, a carbon dioxide laser could used. 5-0 polydioxanone suture on a P-2 needle was to suspend the epiglottis to the base of tongue using 3 sutures. Photographs of the suspension conclude the procedure.

DOI: http://dx.doi.org/10.17797/locmhv8x9q

Robotic Assisted Pediatric Lingual Tonsillectomy

The patient is nasotracheally intubated with a regular cuffed nasotracheal tube. Using a modified McIvor mouth gag, the oral cavity is exposed with the tip of the blade just shy of the posterior 1/3 of tongue so that the tongue base is clearly visualized. The DaVinci robot is set in and using a 5 mm forceps and a mono polar diathermy the incision is made in the midline and the lingual tonsil is dissected out as it is peeled off from the tongue base muscles which is very clearly visualized. The forceps is used to gently retract the tissue while the bovie at a setting of 15 is used to remove the lingual tonsils.. At the end the operative site is irrigated to check for any bleeders. FLOSEAL is also applied to help in hemostasis.

DOI: http://dx.doi.org/10.17797/q82n9gkkvs

Management of subglottic stenosis with endoscopic stent placement

History of airway stenosis, s/p laryngotracheal reconstruction. Developed restenosis, and balloon dilated three times.

In this video we describe our technique for airway stent insertion and its securing to the neck skin.

Balloon dilation of the airway expanded the airway to its appropriate size. After sizing, an 8mm modified Mehta laryngeal stent with rings (Hood Laboratories, Pembroke, Mass., USA)is inserted in the airway with laryngeal forceps. The scope is inserted into the stent to verify its position. Then a 2.0 prolene stitch is taken through the neck, trachea, stent, and taken out through the contralateral skin. This is performed under visualization with a 2.3mm endoscope through the stent. The needle is then re-inserted through the exit puncture and again taken out next to the entry puncture after passing through a subcutaneous tunnel, without re-entering the stent. A small skin incision is performed between the two prolene threads. Multiple knots are taken over an angiocath, which is then buried under the skin.

The stent is taken out 2-6 weeks after the procedure. A neck incision is performed, the angiocath is identified, the knot is cut and the stent is removed under the vision of the endoscope.

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