Pediatric Tracheostomy

Paediatric Tracheostomy

Position the child with chin extension appropriately
Drape the child as shown in the video
Mark the incision line
Use 15 number blade for skin incision
Remove the excessive subcutaneous fat tissue
Find the median raphe and strap muscles
Retract the strap muscles laterally
Identify the tracheal ring
Create the impression of tube for appropriate size incision
Place the stay sutures as shown in the video
incise the trachea with 11 number blade
Secure the maturation sutures
Insert the tracheostomy tube
Confirm the position and then inflate the cuff
Secure the ties and dressing at the end.

Nasopharyngeal Papillomatosis- A combined Transnasal Transoral Coblation Assisted Approach

Title: Nasopharyngeal Papillomatosis- A combined trans nasal transoral coblation assisted approach

Authors –

1. Dr Deepa Shivnani- corresponding author

MBBS, DNB Otolaryngology , MNAMS, Fellowship in Pediatric Otolaryngology

Children’s Airway & Swallowing Center

Manipal Hospital, Bangalore , India

email- deepa.shivnani14@gmail.com

2. Dr E V Raman

MBBS, DLO , MS Otorhinolaryngology

Children’s Airway & Swallowing Center

Manipal Hospital, Bangalore

Here I am presenting a case of 16 yrs old boy, who had nasal block and occasional cough. Nasal endoscopy revealed an exophytic papillomatous growth in the nasopharynx.

MRI showed lesion arising from the nasopharyngeal surface of the soft palate. The lesion was free from the posterior pharyngeal wall. The patient was taken up for the procedure under general anaesthesia.
The transoral approach was followed first. The tissue was taken for histopathological examination followed by a traction suture placed over uvula for better visualisation.

Once exposed, coblation device was used transorally with 45 degree hopkins rod transorally. The tissue was ablated with coblation and coagulation settings of 9:5 respectively.
The base was ablated too, to prevent further recurrence.

Tonsillar pillar retractor was then used for better visualisation and exposure. The coblation was then continued.

The tissue was removed transorally as much as possible then trans nasal approach was performed.

Then, the same coblation device with the same setting was used but the nasal endoscope was changed to O degree Pediatric scope due to space constraints.

The lesion was pushed upward with the help of yankaurs suction tip for better exposure and the remaining tissue was removed with the help of same coblation device.
The lesion was excised completely and successfully with minimal blood loss. The operative area was confirmed with the 70Degree hopkins rod for complete removal of the lesion.

Post operative recovery was uneventful.

Combined transoral trans nasal coblation assisted approach is potential to be safer, easier and less invasive than uvulo palato pharyngoplasty in Pediatric age group specially, in the areas which are difficult to access like nasopharyngeal surface of the soft palate what we showed in this video.

CAC (Coblation Assisted Cordectomy) in Bilateral Vocal Cord Palsy- Tips & Tricks

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 !

Thank you

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